[Federal Register Volume 72, Number 227 (Tuesday, November 27, 2007)]
[Rules and Regulations]
[Pages 66580-67225]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 07-5507]
[[Page 66579]]
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Part III
Book 2 of 2 Books
Pages 66579-67226
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 410, 411, 412, et al.
Medicare and Medicaid Programs; Interim and Final Rule
Federal Register / Vol. 72, No. 227 / Tuesday, November 27, 2007 /
Rules and Regulations
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 410, 411, 412, 413, 414, 416, 419, 482, and 485
[CMS-1392-FC], [CMS-1533-F2], and [CMS-1531-IFC2]
RIN 0938-AO71, RIN 0938-AO70, and RIN 0938-AO35
Medicare Program: Changes to the Hospital Outpatient Prospective
Payment System and CY 2008 Payment Rates, the Ambulatory Surgical
Center Payment System and CY 2008 Payment Rates, the Hospital Inpatient
Prospective Payment System and FY 2008 Payment Rates; and Payments for
Graduate Medical Education for Affiliated Teaching Hospitals in Certain
Emergency Situations Medicare and Medicaid Programs: Hospital
Conditions of Participation; Necessary Provider Designations of
Critical Access Hospitals
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Interim and final rule with comment period.
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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. We describe the 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,
2008. In addition, the rule sets forth the applicable relative payment
weights and amounts for services furnished in ASCs, specific HCPCS
codes to which the final policies of the ASC payment system apply, and
other pertinent rate setting information for the CY 2008 ASC payment
system. Furthermore, this final rule with comment period will make
changes to the policies relating to the necessary provider designations
of critical access hospitals and changes to several of the current
conditions of participation requirements.
The attached document also incorporates the changes to the FY 2008
hospital inpatient prospective payment system (IPPS) payment rates made
as a result of the enactment of the TMA, Abstinence Education, and QI
Programs Extension Act of 2007, Public Law 110-90. In addition, we are
changing the provisions in our previously issued FY 2008 IPPS final
rule and are establishing a new policy, retroactive to October 1, 2007,
of not applying the documentation and coding adjustment to the FY 2008
hospital-specific rates for Medicare-dependent, small rural hospitals
(MDHs) and sole community hospitals (SCHs). In the interim final rule
with comment period in this document, we are modifying our regulations
relating to graduate medical education (GME) payments made to teaching
hospitals that have Medicare affiliation agreements for certain
emergency situations.
DATES: Effective Date: The provisions of this rule are effective on
January 1, 2008.
IPPS Payment Rates: The FY 2008 IPPS payment rates, provided in
section XIX of the preamble of this document, became effective October
1, 2007.
Comment Period: We will consider comments on the payment
classifications assigned to HCPCS codes identified in Addenda B, AA,
and BB to this final rule with the ``NI'' comment indicator, and other
areas specified throughout this rule, at the appropriate address, as
provided below, no later than 5 p.m. EST on January 28, 2008. We will
also consider comments relating to the Medicare GME teaching hospital
affiliated agreement provisions, as provided below, no later than 5
p.m. EST on January 28, 2008.
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 5 p.m. EST on April 1, 2008.
Deadline for Submission of Written Medicare GME Affiliation
Agreements: Written Medicare GME affiliation agreements must be
received by 5 p.m. EST on January 1, 2008.
ADDRESSES: In commenting, please refer to file codes CMS-1392-FC (for
OPPS and ASC matters) or CMS-1531-IFC (for Medicare GME matters), as
appropriate. 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-1392-FC (for OPPS and ASC matters), Attention: CMS-1531-IFC (for
Medicare GME matters), P.O. Box 8013, 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-1392-FC (for OPPS and ASC matters), Attention: CMS-1531-
IFC (for Medicare GME matters), 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) 786-9994 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 who wish to retain proof of filing by
stamping in and retain 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.
Submissions of written Medicare GME affiliation agreements: Written
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Medicare GME affiliation agreements must be sent by regular mail
to:Centers for Medicare and Medicaid Services, Division of Acute Care,
Attention: Elizabeth Troung or Renate Rockwell,Mailstop C4-08-06,7500
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 surgical center issues.
Suzanne Asplen, (410) 786-4558, Partial hospitalization and
community mental health center issues.
Sheila Blackstock, (410) 786-3502, Reporting of quality data
issues.
Mary Collins, (410) 786-3189, and Jeannie Miller, (410) 786-3164,
Necessary provider designations for CAHs issues.
Scott Cooper, (410) 786-9465, and Jeannie Miller, (410) 786-3164,
Hospital conditions of participation issues.
Miechal Lefkowitz, (410) 786-5316, Hospital inpatient prospective
payment system issues.
Tzvi Hefter, (410) 786-4487, Graduate medical education program
issues.
SUPPLEMENTARY INFORMATION:
Submitting Comments: We welcome comments from the public on the
OPPS APC assignments and/or status indicators assigned to HCPCS codes
identified in Addendum B to this final rule with comment period with
comment indicator ``NI'' and on the ASC payment indicators assigned to
HCPCS codes identified in Addenda AA and BB to this final rule with
comment period with comment indicator ``NI'' in order to assist us in
fully considering issues and developing OPPS and ASC payment policies
for those services. You can assist us by referencing file code CMS-
1392-FC.
We also welcome comments from the public on all issues set forth
regarding the revised regulations regarding the Medicare GME
affiliation agreements to assist us in fully considering issues and
developing policies. You can assist us by referencing the file code
CMS-1531-IFC2 and the specific ``issue identifier'' that precedes the
section on which you choose to comment.
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 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 login as guest (no
password required). Dial-in users should use communications software
and modem to call (202) 512-1661; type swais, then login as guest (no
password required).
Alphabetical List of Acronyms Appearing in This Final Rule With Comment
Period
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
CAP Competitive Acquisition Program
CBSA Core-Based Statistical Area
CCR Cost-to-charge ratio
CERT Comprehensive Error Rate Testing
CMHC Community mental health center
CMS Centers for Medicare & Medicaid Services
CoP [Hospital] Condition of participation
CORF Comprehensive outpatient rehabilitation facility
CPT [Physicians'] Current Procedural Terminology, Fourth Edition,
2007, 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
FTE Full-time equivalent
FY Federal fiscal year
GAO Government Accountability Office
GME Graduate medical education
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
HOPD Hospital outpatient department
HOP QDRP Hospital Outpatient Quality Data Reporting Program
ICD-9-CM International Classification of Diseases, Ninth Edition,
Clinical Modification
IDE Investigational device exemption
IME Indirect medical education
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
MIEA-TRHCA Medicare Improvements and Extension Act under Division B,
Title I of the Tax Relief Health Care Act of 2006, Pub. L. 109-432
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
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PM Program memorandum
PPI Producer Price Index
PPS Prospective payment system
PPV Pneumococcal pneumonia vaccine
PRA Paperwork Reduction Act
QIO Quality Improvement Organization
RFA Regulatory Flexibility Act
RHQDAPU Reporting Hospital Quality Data for Annual Payment Update
[Program]
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
WAC Wholesale acquisition cost
In this document, we address several payment systems under the
Medicare program: The hospital outpatient prospective payment system
(OPPS); the revised ambulatory surgical center (ASC) payment system;
the hospital inpatient prospective payment system (IPPS); and payments
for direct and indirect graduate medical education (GME). The
provisions relating to the OPPS are included in sections I. through
XV., XVII., XXI. through XXIV. of this final rule with comment period
and in Addenda A, B, C (Addendum C is available on the Internet only;
see section XXI. of this final rule with comment period), D1, D2, E, L,
and M to this final rule with comment period. The provisions related to
the revised ASC payment system are included in sections XVI., XVII.,
and XXI. through XXIV. of this final rule with comment period and in
Addenda AA, BB, DD1, DD2, and EE (Addendum EE is available on the
Internet only; see section XXI. of this final rule with comment period)
to this final rule with comment period.
The provisions relating to the IPPS payment rates are included in
section XIX., XXIV., and XXV. of this document. The provisions relating
to policy changes to the Medicare GME affiliation provisions for
teaching hospitals in certain emergency situations are included in
sections XX., XXIV., and XXV. of this document.
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 Improvements and Extension Act
under Division B, Title I of the Tax Relief and Health Care Act of
2006
F. Summary of the Major Contents of the CY 2008 OPPS/ASC
Proposed Rule
1. Updates Affecting OPPS Payments
2. OPPS Ambulatory Payment Classification (APC) Group Policies
3. OPPS Payment for Devices
4. OPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals
5. Estimate of OPPS Transitional Pass-Through Spending for
Drugs, Biologicals, and Devices
6. OPPS Payment for Brachytherapy Sources
7. OPPS Coding and Payment for Drug Administration Services
8. OPPS Hospital Coding and Payment for Visits
9. OPPS Payment for Blood and Blood Products
10. OPPS Payment for Observation Services
11. Procedures That Will Be Paid Only as Inpatient Services
12. Nonrecurring Technical and Policy Changes
13. OPPS Payment Status and Comment Indicators
14. OPPS Policy and Payment Recommendations
15. Update of the Revised ASC Payment System
16. Quality Data for Annual Payment Updates
17. Changes Affecting Necessary Provider Critical Access
Hospitals (CAHs) and Hospital Conditions of Participation (CoPs)
18. Regulatory Impact Analysis
G. Public Comments Received in Response to the CY 2008 OPPS/ASC
Proposed Rule
H. Public Comments Received on the November 24, 2006 OPPS/ASC
Final Rule with Comment Period
II. Updates Affecting OPPS Payments
A. Recalibration of APC Relative Weights
1. Database Construction
a. Database Source and Methodology
b. Use of Single and Multiple Procedure Claims
(1) Use of Date of Service Stratification and a Bypass List to
Increase the Amount of Data Used to Determine Medians
(2) Exploration of Allocation of Packaged Costs to Separately
Paid Procedure Codes
c. Calculation of CCRs
2. Calculation of Median Costs
3. Calculation of OPPS Scaled Payment Weights
4. Changes to Packaged Services
a. Background
b. Addressing Growth in OPPS Volume and Spending
c. Packaging Approach
(1) Guidance Services
(2) Image Processing Services
(3) Intraoperative Services
(4) Imaging Supervision and Interpretation Services
(5) Diagnostic Radiopharmaceuticals
(6) Contrast Agents
(7) Observation Services
d. Development of Composite APCs
(1) Background
(2) Low Dose Rate (LDR) Prostate Brachytherapy Composite APC
(a) Background
(b) Payment for LDR Prostate Brachytherapy
(3) Cardiac Electrophysiologic Evaluation and Ablation Composite
APC
(a) Background
(b) Payment for Cardiac Electrophysiologic Evaluation and
Ablation
e. Service-Specific Packaging Issues
B. Payment for Partial Hospitalization
1. Background
2. PHP APC Update
3. Separate Threshold for Outlier Payments to CMHCs
C. Conversion Factor Update
D. Wage Index Changes
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. Hospital Outpatient Outlier Payments
H. Calculation of an Adjusted Medicare Payment from the National
Unadjusted Medicare Payment
I. Beneficiary Copayments
1. Background
2. Copayment
3. Calculation of an Adjusted Copayment Amount for an APC Group
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 April and July
Quarterly OPPS Updates for CY 2007
a. Background
b. Implantation of Interstitial Devices (APC 0156)
c. Other New HCPCS Codes Implemented in April or July 2007
2. Treatment of New Category I and III CPT Codes and Level II
HCPCS Codes
a. Establishment and Assignment of New Codes
b. Electronic Brachytherapy (New Technology APC 1519)
c. Other 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. Positron Emission Tomography (PET)/Computed Tomography (CT)
Scans (APC 0308)
b. IVIG Preadministration-Related Services (APC 0430)
c. Other Services in New Technology APCs
(1) Breast Brachytherapy Catheter Implantation (APC 0648)
(2) Preoperative Services for Lung Volume Reduction Surgery
(LVRS) (APCs 0209 and 0213)
D. APC Specific Policies
1. Cardiac Procedures
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a. Cardiac Computed Tomography and Computed Tomographic
Angiography (APCs 0282 and 0383)
b. Coronary and Non-Coronary Angioplasty (PTCA/PTA)(APCs 0082,
0083, and 0103)
c. Implantation of Cardioverter-Defibrillators (APCs 0107 and
0108)
d. Removal of Patient-Activated Cardiac Event Recorder (APC
0109)
e. Stress Echocardiography (APC 0697)
2. Gastrointestinal Procedures
a. Computed Tomographic Colonography (APC 0332)
b. Laparoscopic Neurostimulator Electrode Implantation (APC
0130)
c. Screening Colonoscopies and Screening Flexible
Sigmoidoscopies (APCs 0158 and 0159)
3. Genitourinary Procedures
a. Cystoscopy with Stent (APC 0163)
b. Percutaneous Renal Cryoablation (APC 0423)
c. Prostatic Thermotherapy (APC 0163)
d. Radiofrequency Ablation of Prostate (APC 0163)
e. Ultrasound Ablation of Uterine Fibroids with Magnetic
Resonance Guidance (MRgFUS) (APC 0067)
f. Uterine Fibroid Embolization (APC 0202)
4. Nervous System Procedures
a. Chemodenervation (APC 0206)
b. Implantation of Intrathecal or Epidural Catheter (APC 0224)
c. Implantation of Spinal Neurostimulators (APC 0222)
5. Nuclear Medicine and Radiation Oncology Procedures
a. Adrenal Imaging (APC 0391)
b. Injection for Sentinel Node Identification (APC 0389)
c. Myocardial Positron Emission Tomography (PET) Scans (APC
0307)
d. Nonmyocardial Positron Emission Tomography (PET) Scans (APC
0308)
e. Proton Beam Therapy (APCs 0664 and 0667)
6. Ocular and Ear, Nose and Throat Procedures
a. Amniotic Membrane for Ocular Surface Reconstruction (APC
0244)
b. Keratoprosthesis (APC 0293)
c. Palatal Implant (New Technology APC 1510)
7. Orthopedic Procedures
a. Arthroscopic Procedures (APCs 0041 and 0042)
b. Closed Fracture Treatment (APC 0043)
c. Insertion of Posterior Spinous Process Distraction Device
(APC 0050)
d. Intradiscal Annuloplasty (APC 0050)
e. Kyphoplasty Procedures (APC 0052)
8. Vascular Procedures
a. Blood Transfusion (APC 0110)
b. Endovenous Ablation (APC 0092)
c. Insertion of Central Venous Access Device (APC 0625)
d. Noninvasive Vascular Studies (APC 0267)
9. Other Procedures
a. Hyperbaric Oxygen Therapy (APC 0659)
b. Skin Repair Procedures (APCs 0133, 0134, 0135, 0136, and
0137)
c. Stereotactic Radiosurgery (SRS) Treatment Delivery Services
(APCs 0065, 0066, and 0067)
10. Medical Services
a. Single Allergy Tests (APC 0381)
b. Continuous Glucose Monitoring (APC 0097)
c. Home International Normalized Ratio (INR) Monitoring (APC
0097)
d. Mental Health Services (APC 0322, 0323, 0324, 0325)
IV. OPPS Payment for Devices
A. Treatment of Device Dependent APCs
1. Background
2. Payment under the OPPS
3. Payment When Devices Are Replaced with Partial Credit to the
Hospital
B. Pass-Through Payments for Devices
1. Expiration of Transitional Pass Through Payments for Certain
Devices
a. Background
b. Final Policy
2. Provisions for Reducing Transitional Pass Through Payments to
Offset Costs Packaged into APC Groups
a. Background
b. Final Policy
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
2007
3. Drugs and Biologicals with Pass-Through Status in CY 2008
B. Payment for Drugs, Biologicals, and Radiopharmaceuticals
without Pass Through Status
1. Background
2. Criteria for Packaging Payment for Drugs and Biologicals
3. Payment for Drugs and Biologicals without Pass Through Status
That Are Not Packaged
a. Payment for Specified Covered Outpatient Drugs
(1) Background
(2) Payment Policy
(3) Payment for Blood Clotting Factors
(a) Background
(b) Payment for Diagnostic Radiopharmaceuticals
(c) Payment for Therapeutic Radiopharmaceuticals
b. Payment for Nonpass-Through Drugs, Biologicals, and
Radiopharmaceuticals with HCPCS Codes, But without OPPS Hospital
Claims Data
VI. Estimate of OPPS Transitional Pass Through Spending for Drugs,
Biologicals, Radiopharmaceuticals, and Devices
A. Total Allowed Pass Through Spending
B. Estimate of Pass Through Spending
VII. OPPS Payment for Brachytherapy Sources
A. Background
B. Payment for Brachytherapy Sources
VIII. OPPS Drug Administration Coding and Payment
A. Background
B. Coding and Payment for Drug Administration Services
IX. Hospital Coding and Payments for Visits
A. Background
B. Policies for Hospital Outpatient Visits
1. Clinic Visits: New and Established Patient Visits and
Consultations
2. Emergency Department Visits
C. Visit Reporting Guidelines
1. Background
2. CY 2007 Work on Visit Guidelines
3. Visit Guidelines
X. OPPS Payment for Blood and Blood Products
A. Background
B. Payment for Blood and Blood Products
XI. OPPS Payment for Observation Services
A. Observation Services (HCPCS Code G0378)
B. Direct Admission to Observation (HCPCS Code G0379)
XII. Procedures That Will Be Paid Only as Inpatient Procedures
A. Background
B. Changes to the Inpatient List
XIII. Nonrecurring Technical and Policy Changes
A. Outpatient Hospital Services and Supplies Incident to a
Physician Service
B. Interrupted Procedures
C. Transitional Adjustments--Hold Harmless Provisions
D. Reporting of Wound Care Services
E. Reporting of Cardiac Rehabilitation Services
F. Reporting of Bone Marrow and Stem Cell Processing Services
G. Reporting of Alcohol and/or Substance Abuse Assessment and
Intervention Services
XIV. OPPS Payment Status and Comment Indicators
A. Payment 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. Comment Indicator Definitions
XV. OPPS Policy and Payment Recommendations
A. MedPAC Recommendations
B. APC Panel Recommendations
XVI. Update of the Revised Ambulatory Surgical Center Payment System
A. Legislative and Regulatory Authority for the ASC Payment
System
B. Rulemaking for the Revised ASC Payment System
C. Revisions to the ASC Payment System Effective January 1, 2008
1. Covered Surgical Procedures under the Revised ASC Payment
System
a. Definition of Surgical Procedure
b. Identification of Surgical Procedures Eligible for Payment
under the Revised ASC Payment System
c. Payment for Covered Surgical Procedures under the Revised ASC
Payment System
(1) General Policies
(2) Office-Based Procedures
(3) Device-Intensive Procedures
(4) Multiple and Interrupted Procedure Discounting
(5) Transition to Revised ASC Payment Rates
[[Page 66584]]
2. Covered Ancillary Services under the Revised ASC Payment
System
a. General Policies
b. Payment Policies for Specific Items and Services
(1) Radiology Services
(2) Brachytherapy Sources
3. General Payment Policies
a. Adjustment for Geographic Wage Differences
b. Beneficiary Coinsurance
D. Treatment of New HCPCS Codes
1. Treatment of New CY 2008 Category I and III CPT Codes and
Level II HCPCS Codes
2. Treatment of New Mid-Year Category III CPT Codes
3. Treatment of Level II HCPCS Codes Released on a Quarterly
Basis
E. Updates to Covered Surgical Procedures and Covered Ancillary
Services
1. Identification of Covered Surgical Procedures
a. General Policies
b. Changes in Designation of Covered Surgical Procedures as
Office-Based
c. Changes in Designation of Covered Surgical Procedures as
Device Intensive
2. Changes in Identification of Covered Ancillary Services
F. Payment for Covered Surgical Procedures and Covered Ancillary
Services
1. Payment for Covered Surgical Procedures
a. Update to Payment Rates
b. Payment Policies When Devices Are Replaced at No Cost or with
Credit
(1) Policy When Devices Are Replaced at No Cost or with Full
Credit
(2) Policy When Implantable Devices Are Replaced with Partial
Credit
2. Payment for Covered Ancillary Services
G. Physician Payment for Procedures and Services Provided in ASC
H. Changes to Definitions of ``Radiology and Certain Other
Imaging Services'' and ``Outpatient Prescription Drugs''
I. New Technology Intraocular Lenses (NTIOLs)
1. Background
2. Changes to the NTIOL Determination Process Finalized for CY
2008
3. NTIOL Application Process for CY 2008 Payment Adjustment
4. Classes of NTIOLS Approved for Payment Adjustment
5. Payment Adjustment
6. CY 2008 ASC Payment for Insertion of IOLs
J. ASC Payment and Comment Indicators
K. ASC Policy and Payment Recommendations
L. Calculation of the ASC Conversion Factor and ASC Payment
Rates
XVII. Reporting Quality Data for Annual Payment Rate Updates
A. Background
1. Reporting Hospital Outpatient Quality Data for Annual Payment
Update
2. Reporting ASC Quality Data for Annual Payment Increase
3. Reporting Hospital Inpatient Quality Data for Annual Payment
Update
B. Hospital Outpatient Measures
C. Other Hospital Outpatient Measures
D. Implementation of the HOP QDRP and Request for Additional
Suggested Measures
E. Requirements for HOP Quality Data Reporting for CY 2009 and
Subsequent Calendar Years
1. Administrative Requirements
2. Data Collection and Submission Requirements
3. HOP QDRP Validation Requirements
F. Publication of HOP QDRP Data Collected
G. Attestation Requirement for Future Payment Years
H. HOP QDRP Reconsiderations
I. Reporting of ASC Quality Data
J. FY 2009 IPPS Quality Measures under the RHQDAPU Program
XVIII. Changes Affecting Critical Access Hospitals (CAHs) and
Hospital Conditions of Participation (CoPs)
A. Changes Affecting CAHs
1. Background
2. Co-Location of Necessary Provider CAHs
3. Provider-Based Facilities of CAHs
4. Termination of Provider Agreement
5. Regulation Changes
B. Revisions to Hospital CoPs
1. Background
2. Provisions of the Final Regulation
a. Timeframes for Completion of the Medical History and Physical
Examination
b. Requirements for Preanesthesia and Postanesthesia Evaluations
c. Technical Amendment to Nursing Services CoP
XIX. Changes to the FY 2008 Hospital Inpatient Prospective Payment
System (IPPS) Payment Rates
A. Background
B. Revised IPPS Payment Rates
1. MS-DRG Documentation and Coding Adjustment
2. Application of the Documentation and Coding Adjustment to the
Hospital Specific Rates
XX. Medicare Graduate Medical Education Affiliation Provisions for
Teaching Hospitals in Certain Emergency Situations
A. Background
1. Legislative Authority
2. Existing Medicare Direct GME and Indirect GME Policies
3. Regulatory Changes Issued in 2006 to Address Certain
Emergency Situations
B. Additional Changes in This Interim Final Rule with Comment
Period
1. Summary of Regulatory Changes
2. Discussion of Training in Nonhospital Settings
C. Responses to Comments on the April 12, 2006 Interim Final
Rule with Comment Period and This Interim Final Rule with Comment
Period
XXI. Files Available to the Public Via the Internet
A. Information in Addenda Related to the Revised CY 2008
Hospital OPPS
B. Information in Addenda Related to the Revised CY 2008 ASC
Payment System
XXII. Collection of Information Requirements
XXIII. Response to Comments
XXIV. Regulatory Impact Analysis
A. Overall Impact of Changes to the OPPS and ASC Payment Systems
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
2. Limitation of Our Analysis
3. Estimated Impact of This Final Rule with Comment Period on
Hospitals and CMHCs
4. Estimated Effect of This Final Rule with Comment Period on
Beneficiaries
5. Conclusion
6. Accounting Statement
C. Effects of ASC Payment System Changes in This Final Rule with
Comment Period
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 Requirements for Reporting of Quality Data for
Hospital Outpatient Settings
E. Effects of the Policy on CAH Off-Campus and Co-Location
Requirements
F. Effects of the Policy Revisions to the Hospital CoPs
G. Effects of the Changes to the Hospital Inpatient Prospective
Payment System (IPPS) Payment Rates
1. Overall Impact
2. Objectives
3. Limitations of Our Analysis
4. Quantitative Effects of the IPPS Policy Changes on Operating
Costs
5. Analysis of Table I
a. Effects of All Changes with CMI Adjustment Prior to Estimated
Growth (Columns 2a and 2b)
b. Effects of All Changes with CMI Adjustment and Estimated
Growth (Column 3)
6. Overall Conclusion
7. Accounting Statement
8. Executive order 12866
H. Impact of the Policy Revisions to the Emergency Medicare GME
Affiliated Groups for Hospitals in Certain Declared Emergency Areas
1. Overall Impact
2. RFA
3. Small Rural Hospitals
4. Unfunded Mandates
5. Federalism
6. Anticipated Effects
7. Alternatives Considered
8. Conclusion
9. Executive Order 12866
XXV. Waiver of Proposed Rulemaking, Waiver of Delay in Effective
Date, and Retroactive Effective Date
A. Requirements for Waivers and Retroactive Rulemaking
B. IPPS Payment Rate Policies
C. Medicare GME Affiliation Agreement Provisions
Regulation Text
Addenda
Addendum A-OPPS APCs for CY 2008
[[Page 66585]]
Addendum AA-ASC Covered Surgical Procedures for CY 2008 (Including
Surgical Procedures for Which Payment is Packaged)
Addendum B-OPPS Payment By HCPCS Code for CY 2008
Addendum BB-ASC Covered Ancillary Services Integral to Covered
Surgical Procedures for CY 2008 (Including Ancillary Services for
Which Payment Is Packaged)
Addendum D1-OPPS Payment Status Indicators
Addendum DD1-ASC Payment Indicators
Addendum D2-OPPS Comment Indicators
Addendum DD2-ASC Comment Indicators
Addendum E-HCPCS Codes That Would Be Paid Only as Inpatient
Procedures for CY 2008
Addendum L-Out-Migration Adjustment
Addendum M-HCPCS Codes for Assignment to Composite APCs for CY 2008
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) to the Social Security Act (the Act) authorizing implementation
of a PPS for hospital outpatient services.
The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act
(BBRA) of 1999 (Pub. L. 106-113) made major changes in the hospital
outpatient prospective payment system (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, also made additional changes in the OPPS. In addition, the
Medicare Improvements and Extension Act under Division B of Title I of
the Tax Relief and Health Care Act (MIEA-TRHCA) of 2006 (Pub. L. 109-
432), enacted on December 20, 2006, made further changes in the OPPS. A
discussion of these changes is included in sections I.E., VII., and
XVII. of this final rule with comment period.
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 the
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 final rule with comment period.
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 hospital inpatient 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 generally use the median cost of the item or service assigned to an
APC group.
For new technology items and services, special payments under the
OPPS may be made 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 payment for screening and diagnostic mammography
services from the OPPS. The Secretary exercised the authority granted
under the statute to also 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 (CLFS); 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
[[Page 66586]]
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 that take into
account changes in medical practices, changes in technologies, 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 continuing experience with
this system. We published in the Federal Register on November 24, 2006
the CY 2007 OPPS/ASC final rule with comment period (71 FR 67960). 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
2007 OPPS on the basis of claims data from January 1, 2005, through
December 31, 2005, and to implement certain provisions of Pub. L. 108-
173 and Pub. L. 109-171. In addition, we responded to public comments
received on the provisions of the November 10, 2005 final rule with
comment period (70 FR 86516) pertaining to the APC assignment of HCPCS
codes identified in Addendum B of that rule with the new interim (NI)
comment indicator; and public comments received on the August 23, 2006
OPPS/ASC proposed rule for CY 2007 (71 FR 49506).
On August 2, 2007, we issued in the Federal Register (72 FR 42628)
a proposed rule for the CY 2008 OPPS/ASC to implement statutory
requirements and changes arising from our continuing experience with
both systems. We received approximately 2,180 pieces of timely
correspondence in response to the proposed rule. A summary of the
public comments we received and our responses to those comments are
included in the specific sections of this 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, and redesignated by section 202(a)(2) 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 final
rule with comment period, 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 clinical data and advises CMS about the clinical
integrity of the APC groups and their payment 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 renewed the APC
Panel's charter three times: On November 1, 2002; on November 1, 2004;
and effective November 21, 2006. The current charter specifies, among
other requirements, that the APC Panel continue to be technical in
nature; be 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 designated by the Secretary.
The current APC Panel membership and other information pertaining
to the APC Panel, including its charter, Federal Register notices,
membership, meeting dates, agenda topics, and meeting reports can be
viewed on the CMS Web site at: http://www.cms.hhs.gov/FACA/05--
AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp#TopOfPage.
3. APC Panel Meetings and Organizational Structure
The APC Panel first met on February 27, February 28, and March 1,
2001. Since the initial meeting, the APC Panel has held 12 subsequent
meetings, with the last meeting taking place on September 5 and 6,
2007. Prior to each meeting, we publish a notice in the Federal
Register to announce the meeting, and when necessary, to solicit
nominations for APC Panel membership, and to announce new members.
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 and Visit 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 and Visit
Subcommittee reviews and makes recommendations to the APC Panel on all
technical issues pertaining to observation services and hospital
outpatient visits paid under the OPPS (for example, APC configurations
and APC payment weights). The Packaging Subcommittee studies and makes
recommendations on issues pertaining to services that are not
separately payable under the OPPS, but whose payments are bundled or
packaged into APC payments. Each of these subcommittees was established
by a majority vote from the full APC Panel during a scheduled APC Panel
meeting, and their continuation as subcommittees was last approved at
the September 2007 APC Panel meetings. All subcommittee recommendations
are discussed and voted upon by the full APC Panel.
Discussions of the recommendations resulting from the APC Panel's
March 2007 and September 2007 meetings are included in the sections of
this final rule with comment period that are specific to each
recommendation. For discussions of earlier APC Panel meetings and
recommendations, we refer readers to previously published hospital OPPS
final rules or the Web site mentioned earlier in this section.
E. Provisions of the Medicare Improvements and Extension Act under
Division B of Title I of the Tax Relief and Health Care Act of 2006
The Medicare Improvements and Extension Act under Division B of
Title I of the Tax Relief and Health Care Act
[[Page 66587]]
(MIEA-TRHCA) of 2006, Pub. L. 109-432, enacted on December 20, 2006,
included the following provisions affecting the OPPS:
1. Section 107(a) of the MIEA-TRHCA amended section 1833(t)(16)(C)
of the Act to extend the period for payment of brachytherapy devices
based on the hospital's charges adjusted to cost for 1 additional year,
through December 31, 2007.
2. Section 107(b)(1) of the MIEA-TRHCA amended section
1833(t)(2)(H) of the Act by adding stranded and non stranded devices
furnished on or after July 1, 2007, as additional classifications of
brachytherapy devices for which separate payment groups must be
established for payment under the OPPS. Section 107(b)(2) of the MIEA
TRCHA provides that the Secretary may implement the section 107(b)(1)
amendment to section 1833(t)(2)(H) of the Act ``by program instruction
or otherwise.''
3. Section 109(a) of the MIEA-TRHCA added new paragraph (17) to
section 1833(t) of the Act which authorizes the Secretary, beginning in
2009 and each subsequent year, to reduce the OPPS full annual update by
2.0 percentage points if a hospital paid under the OPPS fails to submit
data as required by the Secretary in the form and manner specified on
selected measures of quality of care, including medication errors. In
accordance with this provision, the selected measures are those that
are appropriate for the measurement of quality of care furnished by
hospitals in the outpatient setting, that reflect consensus among
affected parties and, to the extent feasible and practicable, that
include measures set forth by one or more of the national consensus
entities, and that may be the same as those required for reporting by
hospitals paid under the IPPS. This provision specifies that a
reduction for 1 year cannot be taken into account when computing the
OPPS update for a subsequent year. In addition, this provision requires
the Secretary to establish a process for making the submitted data
available for public review.
F. Summary of the Major Contents of the CY 2008 OPPS/ASC Proposed Rule
On August 2, 2007, we published a proposed rule in the Federal
Register (72 FR 42628) that set forth proposed changes to the Medicare
hospital OPPS for CY 2008 to implement statutory requirements and
changes arising from our continuing experience with the system and to
implement certain statutory provisions. In addition, we proposed
changes to the revised Medicare ASC payment system for CY 2008 such as
adding procedures to the list of covered surgical procedures and
adjusting the ASC rates so that the revised ASC payment system is
budget neutral. We also proposed to make changes to the policies
relating to the necessary provider designations of CAHs that are being
recertified when a CAH enters into a new co-location arrangement with
another hospital or CAH or when the CAH creates or acquires an off-
campus location. Further, we proposed changes to several of the current
conditions of participation that hospitals must meet to participate in
the Medicare and Medicaid programs to require the completion and
documentation in the medical record of medical histories and physical
examinations of patients conducted after admission and prior to surgery
or a procedure requiring anesthesia services and for postanesthesia
evaluations of patients before discharge or transfer from the
postanesthesia recovery area. Finally, we set forth proposed quality
measures for a Hospital Outpatient Quality Data Reporting (HOP QDRP)
program for reporting quality data for annual payment rate updates for
CY 2009 and subsequent calendar years. We also briefly discussed the
legislative provisions of the MIEA-TRHCA that give the Secretary
authority to develop quality measures for reporting data by ASCs. The
following is a summary of the major changes included in the CY 2008
OPPS/ASC proposed rule:
1. Updates Affecting OPPS Payments
In section II. of the proposed rule, we set forth--
The methodology used to recalibrate the proposed APC
relative payment weights.
The proposed payment for partial hospitalization services,
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.
The proposed retention of our current policy to use the
IPPS wage indices to adjust, for geographic wage differences, the
portion of the OPPS payment rate and the copayment standardized amount
attributable to labor related cost.
The proposed update of statewide average default CCRs.
The proposed application of hold harmless transitional
outpatient payments (TOPs) for certain small rural hospitals.
The proposed payment adjustment for rural SCHs.
The proposed calculation of the hospital outpatient
outlier payment.
The calculation of the proposed national unadjusted
Medicare OPPS payment.
The proposed beneficiary copayments for OPPS services.
2. OPPS Ambulatory Payment Classification (APC) Group Policies
In section III. of the proposed rule, we discussed the proposed
additions of new procedure codes to the APCs; our proposal to establish
a number of new APCs; and our analyses of Medicare claims data and
certain recommendations of the APC Panel. We also discussed the
application of the 2 times rule and proposed exceptions to it; proposed
changes to specific APCs; and the proposed movement of procedures from
New Technology APCs to clinical APCs.
3. OPPS Payment for Devices
In section IV. of the proposed rule, we discussed proposed payment
for device dependent APCs and pass-through payment for specific
categories of devices.
4. OPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals
In section V. of the proposed rule, we discussed the proposed CY
2008 OPPS payment for drugs, biologicals, and radiopharmaceuticals,
including the proposed payment for drugs, biologicals, and
radiopharmaceuticals with and without pass-through status.
5. Estimate of OPPS Transitional Pass-Through Spending for Drugs,
Biologicals, and Devices
In section VI. of the proposed rule, we discussed the estimate of
CY 2008 OPPS transitional pass-through spending for drugs, biologicals,
and devices.
6. OPPS Payment for Brachytherapy Sources
In section VII. of the proposed rule, we discussed our proposal
concerning coding and payment for brachytherapy sources.
7. OPPS Coding and Payment for Drug Administration Services
In section VIII. of the proposed rule, we set forth our proposed
policy concerning coding and payment for drug administration services.
8. OPPS Hospital Coding and Payments for Visits
In section IX. of the proposed rule, we set forth our proposed
policies for the coding and reporting of clinic and emergency
department visits and
[[Page 66588]]
critical care services on claims paid under the OPPS.
9. OPPS Payment for Blood and Blood Products
In section X. of the proposed rule, we discussed our proposed
payment for blood and blood products.
10. Proposed OPPS Payment for Observation Services
In section XI. of the proposed rule, we discussed the proposed
payment policies for observation services furnished to patients on an
outpatient basis.
11. Procedures That Will Be Paid Only as Inpatient Services
In section XII. of the proposed rule, we discussed the procedures
that we proposed to remove from the inpatient list and assign to APCs.
12. Nonrecurring Technical and Policy Changes
In section XIII. of the proposed rule, we set forth our proposals
for nonrecurring technical and policy changes and clarifications
relating to outpatient services and supplies incident to physicians'
services; payment for interrupted procedures prior to and after the
administration of anesthesia; transitional adjustments to payments for
covered outpatient services furnished by small rural hospitals and SCHs
located in rural areas; and reporting requirements for wound care
services, cardiac rehabilitation services, and bone marrow and stem
cell processing services.
13. OPPS Payment Status and Comment Indicators
In section XIV. of the proposed rule, we discussed proposed changes
to the definitions of status indicators assigned to APCs and presented
our proposed comment indicators for the OPPS/ASC final rule with
comment period.
14. OPPS Policy and Payment Recommendations
In section XV. of the proposed rule, we addressed recommendations
made by the Medicare Payment Advisory Commission (MedPAC) in its March
and June 2007 Reports to Congress and by the APC Panel regarding the
OPPS for CY 2008.
15. Update of the Revised ASC Payment System
In section XVI. of the proposed rule, we discussed the proposed
update of the revised ASC payment system payment rates for CY 2008. We
also discussed our proposed changes to our regulations at Sec. Sec.
414.22(b)(5)(i)(A) and (B) regarding physician payment for performing
excluded surgical procedures in ASCs. In addition, we set forth our
proposal to revise the definitions of ``radiology and certain other
imaging services'' and ``outpatient prescription drugs'' when provided
integral to an ASC covered surgical procedure.
16. Reporting Quality Data for Annual Payment Rate Updates
In section XVII. of the proposed rule, we discussed the proposed
quality measures for reporting hospital outpatient quality data for CY
2009 and subsequent years and set forth the requirements for data
collection and submission for the annual payment update. We also
briefly discussed the legislative provisions of the MIEA-TRHCA that
give the Secretary authority to develop quality measures for reporting
by ASCs. (We note that, as discussed in section XVII.J. of this final
rule with comment period, we are also finalizing a proposal from the FY
2008 IPPS proposed rule relating to the FY 2009 RHQDAPU quality
measures. Specifically, we are finalizing the inclusion of SCIP
Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative
Serum Glucose and SCIP Infection 6: Surgery Patients with Appropriate
Hair Removal in the FY 2009 RHQDAPU measure set, bringing the total
number of measures in that measure set to 30.)
17. Changes Affecting Necessary Provider Critical Access Hospitals
(CAHs) and Hospital Conditions of Participation (CoPs)
In section XVIII. of the proposed rule, we discussed our proposed
changes affecting CAHs both when the CAH enters into a new co-location
arrangement with another hospital or CAH and when the CAH creates or
acquires a provider-based off campus location. We also discussed our
proposed changes relating to several hospital CoPs to require the
completion of physical examinations and medical histories and
documentation in the medical records for patients after admission and
prior to surgery or a procedure requiring anesthesia services, and for
postanesthesia evaluations of patients after surgery or a procedure
requiring anesthesia services but before discharge or transfer from the
postanesthesia recovery area.
18. Regulatory Impact Analysis
In section XXII. of the proposed rule, we set forth an analysis of
the impact the proposed changes would have on affected entities and
beneficiaries. (We note that this regulatory impact analysis section is
redesignated as section XXIV. of this final rule with comment period.)
G. Public Comments Received in Response to the CY 2008 OPPS/ASC
Proposed Rule
We received approximately 2,180 timely pieces of correspondence
containing multiple comments on the CY 2008 OPPS/ASC proposed rule. We
note that we received some comments that were outside the scope of the
CY 2008 OPS/ASC proposed rule. These comments are not addressed in this
CY 2008 OPPS/ASC final rule with comment period. Summaries of the
public comments that are within the scope of the proposals and our
responses to those comments are set forth in the various sections of
this final rule with comment period under the appropriate headings.
H. Public Comments Received on the November 24, 2006 OPPS/ASC Final
Rule with Comment Period
We received approximately 21 timely items of correspondence on the
CY 2007 OPPS/ASC final rule with comment period, some of which
contained multiple comments on the interim final APC assignments and/or
status indicators of HCPCS codes identified with comment indicator
``NI'' in Addendum B to that final rule with comment period. Summaries
of those public comments and our responses to them are set forth in the
various sections of this final rule with comment period under the
appropriate headings.
II. Updates Affecting OPPS Payments
A. Recalibration of APC Relative Weights
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).
In the CY 2008 OPPS/ASC proposed rule, we proposed to use the same
basic methodology that we described in the
[[Page 66589]]
April 7, 2000 OPPS final rule with comment period to recalibrate the
APC relative payment weights for services furnished on or after January
1, 2008 and before January 1, 2009. That is, we proposed to 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 proposed APC relative
payment weights for CY 2008, we used approximately 131 million final
action claims for hospital outpatient department (HOPD) services
furnished on or after January 1, 2006 and before January 1, 2007. (For
exact counts of claims used, we refer readers to the claims accounting
narrative under supporting documentation for the proposed rule on the
CMS Web site at: http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/).
Of the 141 million final action claims for services provided in
hospital outpatient settings used to calculate the CY 2008 OPPS payment
rates for this final rule with comment period, approximately 103
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 103 million claims,
approximately 45 million were not for services paid under the OPPS or
were excluded as not appropriate for use (for example, erroneous cost-
to-charge ratios (CCRs) or no HCPCS codes reported on the claim). We
were able to use approximately 54 million whole claims of the
approximately 58 million claims that remained to set the OPPS APC
relative weights for the CY 2008 OPPS. From the 54 million whole
claims, we created approximately 97 million single records, of which
approximately 65 million were ``pseudo'' single claims (created from
multiple procedure claims using the process we discuss in this
section). Approximately 926,000 claims trimmed out on cost or units in
excess of +/-3 standard deviations from the geometric mean, yielding
approximately 96 million single bills used for median setting.
Ultimately, we were able to use for CY 2008 ratesetting some portion of
93 ercent of the CY 2006 claims containing services payable under the
OPPS. This is approximately the same percentage of CY 2005 claims where
some portion could be used for CY 2007 ratesetting as described in the
CY 2007 OPPS/ASC final rule with comment period (71 FR 67970).
As proposed, the final APC relative weights and payments for CY
2008 in Addenda A and B to this final rule with comment period were
calculated using claims from this period that were processed before
June 30, 2007, 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. We
continue to believe that it is appropriate to use the most current full
calendar year claims data and the most recently submitted cost reports
to calculate the median costs which we proposed to convert to relative
payment weights for purposes of calculating the CY 2008 payment rates.
We did not receive any comments on our proposal to base the CY 2008
APC relative weights on the most currently available cost reports and
on claims for services furnished in CY 2006. Therefore, we are
finalizing our data source for the recalibration of the CY 2008 APC
relative payment weights as proposed, without modification, as
described in this section of this final rule with comment period.
b. Use of Single and Multiple Procedure Claims
For CY 2008, in general, we proposed to continue to use single
procedure claims to set the medians on which the APC relative payment
weights would be based, with some exceptions as discussed below. We
generally use single procedure claims to set the median costs for APCs
because we believe that it is important that the OPPS relative weights
on which payment rates are based be appropriate when one and only one
procedure is furnished and 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. 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 claims for multiple procedures. We engaged in several efforts
this year to improve our use of multiple procedure claims for
ratesetting. As we have for several years, we continued to use date of
service stratification and a list of codes to be bypassed to convert
multiple procedure claims to ``pseudo'' single procedure claims. We
also continued our internal efforts to better understand the patterns
of services and costs from multiple bills toward the goal of using more
multiple bill information by assessing the amount of packaging in the
multiple bills and, specifically, by exploring the amount of packaging
for drug administration services in the single and multiple bill
claims. Moreover, in many cases, the packaging approach that we
proposed for the CY 2008 OPPS also allows the use of more claims data
by enabling us to treat claims with multiple procedure codes as single
claims. We refer readers to section II.A.4. of the proposed rule for a
full discussion of the packaging approach for CY 2008.
We received several public comments on our proposed use of single
bills to calculate the APC median costs for ratesetting under the CY
2008 OPPS. A summary of the public comments and our responses follow.
Comment: Some commenters supported the ``natural'' and ``pseudo''
single methodology but asked that CMS continue to refine the approach
in order to improve the accuracy of the estimates because the medians
are used to develop payment rates for services on both single and
multiple procedure claims. Other commenters asserted that continued
reliance on single procedure bills to establish the medians from which
the rates were calculated failed to produce a statistically valid
sample of services for ratesetting, in particular for brachytherapy
services that are often provided in combination with one another in a
single encounter. Other commenters requested that CMS explore
additional revisions to the current methodology to ensure that OPPS
payment would be based on a substantial number of accurate hospital
claims.
Response: We generally base median costs for services on single
procedure claims to ensure that the median cost captures the full cost
of a service when it is the only service furnished. We recognize that
this approach has limitations and, in some cases, prevents us from
using many of the claims for services that are most commonly furnished
at the same time as other services. For this reason, we have developed
a number of different strategies, such as date of service
stratification and the use of the bypass list, that enable us to break
multiple procedure claims into ``pseudo'' single procedure claims where
we have confidence that the ``pseudo'' single claim contains the full
cost of the service, including related packaged costs. In recent years,
however, we have increasingly used multiple procedure claims to develop
median costs for individual services or groups of services. We have
developed these methodologies so that we can use more naturally
occurring claims data in cases in which care is most commonly reported
with multiple major procedure
[[Page 66590]]
codes on the same date, such as observation services, hyperbaric oxygen
therapy (HBOT), and single allergy tests.
Similarly, for CY 2008, we developed and proposed composite APCs
for low dose rate prostate brachytherapy (APC 8001 (LDR Prostate
Brachytherapy Composite)) and cardiac electrophysiology services (APC
8000 (Cardiac Electrophysiologic Evaluation and Ablation Composite)).
These APCs are designed to use multiple procedure claims to establish a
median cost and APC payment for multiple major procedures when they are
furnished together. As we discuss in section II.A.4.d. of this final
rule with comment period, we intend to explore the creation of
additional composite APCs for services that frequently are provided in
the same HOPD encounter. We also plan to continue to develop and refine
methods to increase the amount of claims data that we can use for
setting OPPS payment rates in a manner that gives us the most
confidence that the costs derived from these approaches are valid
reflections of the costs of the services described by HCPCS codes or,
in the case of composite APCs, described by the APCs. We anticipate
that the Data Subcommittee of the APC Panel will continue to provide us
with valuable advice regarding possible methodologies for increasing
the OPPS use of multiple procedure claims for ratesetting.
After consideration of the public comments received, we are
finalizing our proposal, without modification, to calculate median
costs for APCs using single and ``pseudo'' single procedure claims,
except where otherwise specified.
(1) Use of Date of Service Stratification and a Bypass List To Increase
the Amount of Data Used To Determine Medians
Through 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
numerous separately paid procedures reported on the same date on one
claim. We refer to these newly created single procedure claims as
``pseudo'' single claims because they were submitted by providers as
multiple procedure claims. The history of our use of a bypass list to
generate ``pseudo'' single claims is well documented, most recently in
the CY 2007 OPPS/ASC final rule with comment period (71 FR 67969
through 67970).
The date of service stratification (sorting the lines by date of
service and treating all lines with the same date of service as a
separate claim) and bypass list process we used for the CY 2007 OPPS
(combined with the packaging changes we proposed in section II.A.4. of
the proposed rule) resulted in our being able to use some part of
approximately 92 percent of the total claims that were eligible for use
in the OPPS ratesetting and modeling for the proposed rule. This
process enabled us to create, for the CY 2008 proposed rule,
approximately 58 million ``pseudo'' singles and approximately 30
million ``natural'' single bills. For the proposed rule, ``pseudo''
single procedure bills represented 66 percent of all single bills used
to calculate median costs. This compared favorably to the CY 2007 OPPS
final rule data in which ``pseudo'' single bills represented 68 percent
of all single bills used to calculate the median costs on which the CY
2007 OPPS payment rates were based. We believed that the reduction in
the percent of ``pseudo'' single bills and the corresponding increase
in the proportion of ``natural'' single bills observed for the CY 2008
proposed rule occurred largely because of our proposal to increase
packaging as discussed in section II.A.4. of the proposed rule. In many
cases, the packaging proposal for CY 2008 enabled us to use claims that
would otherwise have been considered to be multiple procedure claims
and, absent the proposal for additional packaging, could have been used
for ratesetting only if we had been able to create ``pseudo'' single
claims from them.
For CY 2008, we proposed to bypass 425 HCPCS codes that are
identified in Table 1 of the proposed rule. We proposed to continue the
use of the codes on the CY 2007 OPPS bypass list but to remove codes we
proposed to package for CY 2008. We also proposed to remove codes that
were on the CY 2007 bypass list that ceased to meet the empirical
criteria under the proposed packaging changes when clinical review
confirmed that their removal would be appropriate in the context of the
full proposal for the CY 2008 OPPS. Since the inception of the bypass
list, we have calculated the percent of ``natural'' single bills that
contained packaging for each code and the amount of packaging in each
``natural'' single bill for each code. We retained the codes on the
previous year's bypass list and used the update year's data to
determine whether it would be appropriate to add additional codes to
the previous year's bypass list. The entire list (including the codes
that remained on the bypass list from prior years) was open to public
comment. For the CY 2008 proposed rule, we explicitly reviewed all
``natural'' single bills against the empirical criteria for all codes
on the CY 2007 bypass list because of the proposal for greater
packaging discussed in section II.A.4. of the proposed rule, as this
effort increased the packaging associated with some codes. We removed
106 HCPCS codes from the CY 2007 bypass list for the CY 2008 proposal.
In addition, we note that many of the codes we proposed to newly
package for CY 2008 were on the bypass list used for setting the OPPS
payment rates for CY 2007 and were not proposed for bypass because we
also proposed to package them. We proposed to add to the bypass list
HCPCS codes that, using the proposed rule data, met the same previously
established empirical criteria for the bypass list that are reviewed
below or which our clinicians believed would have little associated
packaging if the services were coded correctly.
The CY 2008 packaging proposal minimally reduced the percentage of
total claims that we were able to use, in whole or in part, from 93
percent for CY 2007 to 92 percent for the proposed rule. The proposed
packaging approach increased the number of ``natural'' single bills, in
spite of reducing the universe of codes requiring single bills for
ratesetting, but reduced the number of ``pseudo'' single bills. More
``natural'' single procedure bills can be created by the packaging of
codes that always appear with another procedure because these dependent
services are supportive of and ancillary to the primary independent
procedures for which payment is being made. A claim containing two
independent procedure codes on the same date of service and not on the
bypass list previously could not be used for ratesetting, but packaging
the cost of one of the codes on the claim frees the claim to be used to
calculate the median cost of the procedure that is not packaged. On the
other hand, our proposed packaging approach reduced the number of codes
eligible for the bypass list because of the limitation on packaging set
by our previously established empirical criteria. A smaller bypass list
and the presence of greater packaging on claims reduced the final
number of ``pseudo'' single claims. In prior years, roughly 68 percent
of single bills were ``pseudo'' single bills, but based on the CY 2008
proposed rule data, 66 percent of single bills were ``pseudo'' singles.
Similarly, for this final rule with comment period,
[[Page 66591]]
66 percent of single bills were ``pseudo'' singles. Moreover, the
numbers of ``natural'' single bills and ``pseudo'' single bills were
reduced by the volume of services that we proposed to package. Hence,
our CY 2008 proposal to package payment for some HCPCS codes with
relatively high frequencies would eliminate for ratesetting the number
of available ``natural'' and ``pseudo'' single bills attributable to
the codes that we proposed to package.
As in prior years, we proposed to use the following empirical
criteria to determine the additional codes to add to the CY 2007 bypass
list to create the CY 2008 bypass list. We assumed that the
representation of packaging in the single claims for any given code was
comparable to packaging for that code in the multiple claims:
There are 100 or more single claims for the code. This
number of single claims ensures that observed outcomes are sufficiently
representative of packaging that might occur in the multiple claims.
Five percent or fewer of the single claims for the code
have packaged costs on that single claim for the code. This criterion
results in limiting the amount of packaging being redistributed to the
separately 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
is 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 have minimal associated packaging based on their
clinical assessment of the complete CY 2008 OPPS proposal. As proposed,
this list contained bypass codes that were appropriate to claims for
services in CY 2006 and, therefore, included codes that were deleted
for CY 2007. Moreover, there were codes on the proposed bypass list
that were new for CY 2007 and which were appropriate additions to the
bypass list in preparation for use of the CY 2007 claims for creation
of the CY 2009 OPPS.
We received a number of public comments on the use of the bypass
list for creation of ``pseudo'' single procedure claims. A summary of
the comments and our responses follow.
Comment: Some commenters objected to the removal of HCPCS codes
from the bypass list because the codes ceased to meet the criteria for
the bypass list as a result of increased packaging in the ``natural''
single claims due to the proposed packaging approach. The commenters
objected to the removal of codes from the bypass list for this reason
because they asserted that it caused claims that would otherwise have
become ``pseudo'' single claims to not be used and, thereby, reduced
the number of single bills that were available for ratesetting for
certain services.
Response: We agree with the commenters, so we have reevaluated the
bypass list for this final rule with comment period and restored a
number of codes on the bypass list prior to the CY 2008 proposal to
maximize the creation of single and ``pseudo'' single procedure bills.
As we discuss later in this section and in section II.A.4. of this
final rule with comment period, we have made changes to the data
process to ensure that we capture as much data as possible for services
assigned status indicator ``Q.'' Although we revised the process to
apply the specific ``Q'' status indicator policies before assessment of
the bypass list so that additional HCPCS codes could be considered for
the bypass list without risk of losing their data regarding packaging,
we determined that no codes with status indicator ``Q'' were
appropriate for addition to the final CY 2008 bypass list because of
their significant associated packaging.
Comment: Several commenters asked that CMS add certain HCPCS codes
to the bypass list so that more single bills would be available for
median setting. Some commenters specifically objected to the removal of
the following radiation oncology services that they indicated should
seldom have any associated packaging: CPT codes 77280 (Therapeutic
radiology simulation-aided field setting; simple); 77285 (Therapeutic
radiology simulation-aided field setting; intermediate); 77290
(Therapeutic radiology simulation-aided field setting; complex); 77295
(Therapeutic radiology simulation-aided field setting; 3-dimensional);
77332 (Treatment devices, design and construction; simple (simple
block, simple bolus)); 77333 (Treatment devices, design and
construction; intermediate (multiple blocks, stents, bite blocks,
special bolus)); 77334 (Treatment devices, design and construction;
complex (irregular blocks, special shields, compensators, wedges, molds
or casts)); and 77417 (Therapeutic radiology port film(s)). One
commenter explained that there was an interaction with the packaging of
image guided radiation therapy codes that reduced the percentage of
single bills for high dose rate (HDR) brachytherapy from 62 percent to
48 percent of the total frequency. The commenter believed that the
payment for APC 0313 (Brachytherapy) dropped from $789.70 in CY 2007 to
$739.46 in the CY 2008 proposed rule because there were packaged costs
on claims that could no longer be used because the multiple procedure
claims included codes that were removed from the bypass list. The
commenter asked that these codes be restored to the bypass list so that
these claims could be used. Other commenters asked that CMS place CPT
code 93017 (Cardiovascular stress test using maximal or submaximal
treadmill or bicycle exercise, continuous electrocardiographic
monitoring, and/or pharmacological stress; tracing only, without
interpretation and report) on the bypass list because it is typically
performed with single photon emission computed tomography (SPECT)
procedures (CPT code 78465 (Myocardial perfusion imaging; tomographic
(SPECT), multiple studies (including attenuation correction when
performed), at rest and/or stress (exercise and/or pharmacologic) and
redistribution and/or rest injection, without or without
quantification)). These commenters believed that significant data from
multiple procedure claims were lost because CPT code 93017 was not
bypassed. Other commenters asked that CMS add the following drug
administration CPT codes to the bypass list because doing so would
enable use of more multiple procedure claims data to establish median
costs for drug administration services: CPT codes 90767 (Intravenous
infusion, for 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 therapy, prophylaxis, or diagnosis (specify substance or drug);
concurrent infusion (List separately in addition to code for primary
procedure); 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)); 96411 (Chemotherapy administration; intravenous,
push technique, each additional substance/drug (List separately in
addition to code for primary procedure)); and 96417 (Chemotherapy
administration, intravenous infusion technique; each additional
sequential infusion (different substance/drug), up to 1 hour (List
[[Page 66592]]
separately in addition to code for primary procedure)). A commenter
asked that we add HCPCS code 88307 (Level V Surgical pathology, gross
and microscopic examination) because it is so similar to HCPCS codes
88305 (Level III Surgical pathology, gross and microscopic examination)
and 88306 (Level IV Surgical pathology, gross and microscopic
examination) that were already included on the bypass list.
Response: We have reviewed the requests to add these codes to the
bypass list and we have made the following decisions for CY 2008 for
the reasons stated below:
We have added the radiation oncology services listed above, with
the exception of CPT code 77417, to the bypass list because we agree
that they are of the type that should not have packaging associated
with them. We recognize that including them on the bypass list may
yield significantly more single procedure bills and may also increase
the number of claims that we can use for calculation of the low dose
rate prostate brachytherapy composite APC (APC8001). We have not added
CPT code 77417 to the CY 2008 bypass list because, based on its final
CY 2008 unconditionally packaged status, the code would not be a
candidate for the bypass list. Unconditionally packaged codes are not
included on the bypass list because their presence on a claim does not
make that claim a multiple procedure bill.
We have added CPT code 93017 to the bypass list because we agree
that it should not have significant associated packaging, and we
recognize that including it on the bypass list may yield significantly
more single procedure bills for median setting.
We have not added the drug administration services listed above to
the bypass list. Four of these five codes are for sequential drug
infusion services or injections of additional drugs and, therefore, by
definition, new drugs and medical supplies that are associated with
these codes should be reported in all cases in which the services are
furnished. We note that, beginning in CY 2007, we placed the CPT codes
for additional hours of infusion on the bypass list, recognizing that
all packaging related to these hours would be associated with the
initial services on the claim. We proposed and finalized this approach
for CY 2007, because we were unable to accurately assign representative
portions of packaged costs to multiple different drug administration
services. We expected that the packaging related to additional hours of
infusion of drugs that spanned several hours would be appropriately
assigned to the code for the first hour of infusion on the same claim.
If we had not placed the codes for additional hours of infusion on the
bypass list, we would have had a substantial set of drug administration
multiple procedure claims that were unusable for ratesetting purposes.
However, adding the sequential drug administration services to the
bypass list too would force all of the costs of the associated
additional drugs and supplies to be packaged into the payment for the
initial drug administration service for another drug, which we do not
believe is an appropriate allocation of packaging. While we understand
the concerns of the commenters regarding the challenges associated with
setting appropriate payment rates for these sequential services
reported on multiple procedure claims, we have very little CY 2006
claims data for the four codes because they were not recognized for
payment under the CY 2006 OPPS. We will reconsider the treatment of
these CPT codes for the CY 2009 OPPS update when CY 2007 data, where
these codes were separately paid under the OPPS, are available. We have
not added CPT code 90768 to the bypass list because our final CY 2008
policy unconditionally packages payment for this service and,
therefore, it is not a candidate for the bypass list.
We agree that HCPCS code 88307 (which was on the proposed bypass
list for the CY 2008 OPPS) is appropriate and we have added it to the
final CY 2008 bypass list.
In addition to these responses to comments, we have added six other
HCPCS codes to the final CY 2008 bypass list that met the empirical
criteria for inclusion using the final rule data, and we have also
added three HCPCS codes for clinical consistency with codes that are
already on the bypass list. New bypass codes for this final rule with
comment period are identified in Table 1 with an asterisk.
Comment: One commenter objected to the use of the bypass list to
create ``pseudo'' single claims for median setting on the basis that it
artificially lowers the median cost of the services on the bypass list
by sending all packaging on the claim to the other major separately
paid service on the claim. Specifically, the commenter believed that
inclusion of CPT code 93880 (Duplex scan of extracranial arteries;
complete bilateral study) on the bypass list resulted in the use of the
cost data for the lowest cost services and, thereby, lowered the cost
of this service. The commenter stated that CMS should work with
stakeholders on use of the bypass list, its impact on median costs, and
ways that CMS could use data that were more reflective of the real
costs for these procedures. The commenter believed that the median cost
of CPT code 93880 should be based on the cost of the typical patient
and not the least expensive patient because the OPPS payment caps
payment in the physician's office for the service. The commenter
explained that using the bypass list to generate more ``pseudo'' single
claims without any packaging resulted in stagnation in payment that
encouraged hospitals to pressure physicians to order more expensive
tests and threatened access to care for beneficiaries who would be
served well by simpler tests that were being underpaid as a result of
inclusion of CPT code 93880 on the bypass list.
One commenter asked that CMS provide a code-specific analysis of
the impact of bypassing each code on the bypass list because the
commenter believed that removing and using the line item costs for the
bypass codes to set the median costs for the APCs to which the bypass
codes are assigned results in understatement of the median costs for
those APCs.
Response: The bypass list has been very effective in enabling us to
use claims data that would not otherwise be available for median
calculation. Since its origin for the CY 2004 OPPS, we have been very
careful in determining the codes to be placed on the bypass list. As
described above, we use a standard set of criteria to select claims
that seldom have packaging (that is, fewer than 5 percent of
``natural'' single bills); that have little packaging (that is, less
than $50); for which we have at least 100 ``natural'' single bills; and
that are not unlisted codes (for which there is no specified service).
In addition to codes that pass these criteria, we also have added HCPCS
codes to the bypass list that have been recommended to us by members of
the public, including the specialty societies that are most familiar
with them, as services with which packaging should be seldom, if ever,
associated. Therefore, we believe that we have been very prudent with
regard to our selection of the codes to be added to the bypass list and
with our use of the list. Moreover, we open the criteria and the list
to public comment each year and we respond to comments in the final
rule for the update year.
We also make available the claims data used to calculate the median
costs on which the relative weights are based, and we provide an
extensive narrative description of our data process. Hence, we provide
commenters with the tools to conduct any further analyses they chose
with regard to the codes on the
[[Page 66593]]
bypass list or otherwise. In the case of CPT code 93880, the median
packaged cost on ``natural'' single procedure claims (of which there
were 403,106) was $0 and the percent of natural single procedure claims
on which there was any packaging was 0.47 percent (1,899 claims out of
403,106 ). Therefore, the code meets the criteria for inclusion on the
bypass list and will remain on it for CY 2008. We have no evidence that
physicians or hospitals are billing more expensive tests as a result of
the OPPS payment rate for CPT code 93880, and our data show there is
very little packaging associated with the service in the typical case.
In order to keep the established empirical criteria for the bypass
list constant, we specifically solicited public comment on whether we
should adjust the $50 packaging cost criterion for inflation each year
and, if so, recommendations for the source of the adjustment. We
believed that adding an inflation adjustment factor would ensure that
the same amount of packaging associated with candidate codes for the
bypass list was reviewed each year relative to nominal costs.
We received one public comment on the appropriateness of updating
the $50 packaging cost criteria for inclusion of a code on the bypass
list to account for annual inflation. A summary of the comment and our
response follow.
Comment: One commenter stated that CMS should update the $50
maximum ``natural'' single bill median packaging cost criterion for
including HCPCS codes on the bypass list on the basis of empirical
criteria. The commenter did not suggest a methodology we might use for
the update.
Response: We have not changed the $50 maximum ``natural'' bill
median packaging cost criterion for this final rule with comment
period. However, we will consider whether to update the criterion and,
if so, what methodology would be used, as part of the development of
the proposals for the CY 2009 OPPS.
After consideration of the public comments received, we are
adopting, as final, the proposed ``pseudo'' single claims process and
the CY 2008 bypass codes listed in Table 1 below. This list has been
modified from the CY 2008 proposed list, with the addition of HCPCS
codes that meet the empirical criteria based on updated claims data and
certain HCPCS codes recommended by commenters, as discussed above. As
stated earlier, the new bypass codes for this final rule with comment
period are identified in Table 1 with an asterisk.
Table 1.--CY 2008 Final Bypass Codes for Creating ``Pseudo'' Single
Claims for Calculating Median Costs
------------------------------------------------------------------------
Added for
HCPCS code Short description this final
rule
------------------------------------------------------------------------
11056...................... Trim skin lesions, 2 to 4....
11057...................... Trim skin lesions, over 4....
11300...................... Shave skin lesion............
11301...................... Shave skin lesion............
11719...................... Trim nail(s).................
11720...................... Debride nail, 1-5............
11721...................... Debride nail, 6 or more......
11954...................... Therapy for contour defects..
17003...................... Destruct premalg les, 2-14...
31231...................... Nasal endoscopy, dx..........
31579...................... Diagnostic laryngoscopy......
51798...................... Us urine capacity measure....
53661...................... Dilation of urethra.......... *
54240...................... Penis study..................
56820...................... Exam of vulva w/scope........
57150...................... Treat vagina infection....... *
67820...................... Revise eyelashes.............
69210...................... Remove impacted ear wax......
69220...................... Clean out mastoid cavity.....
70030...................... X-ray eye for foreign body...
70100...................... X-ray exam of jaw............
70110...................... X-ray exam of jaw............
70120...................... X-ray exam of mastoids.......
70130...................... X-ray exam of mastoids.......
70140...................... X-ray exam of facial bones...
70150...................... X-ray exam of facial bones...
70160...................... X-ray exam of nasal bones....
70200...................... X-ray exam of eye sockets....
70210...................... X-ray exam of sinuses........
70220...................... X-ray exam of sinuses........
70250...................... X-ray exam of skull..........
70260...................... X-ray exam of skull..........
70328...................... X-ray exam of jaw joint......
70330...................... X-ray exam of jaw joints.....
70336...................... Magnetic image, jaw joint....
70355...................... Panoramic x-ray of jaws......
70360...................... X-ray exam of neck...........
70370...................... Throat x-ray & fluoroscopy...
70371...................... Speech evaluation, complex...
70450...................... Ct head/brain w/o dye........
70480...................... Ct orbit/ear/fossa w/o dye...
70486...................... Ct maxillofacial w/o dye.....
70490...................... Ct soft tissue neck w/o dye..
70544...................... Mr angiography head w/o dye..
70551...................... Mri brain w/o dye............
71010...................... Chest x-ray..................
71015...................... Chest x-ray..................
71020...................... Chest x-ray..................
71021...................... Chest x-ray..................
71022...................... Chest x-ray..................
71023...................... Chest x-ray and fluoroscopy..
71030...................... Chest x-ray..................
71034...................... Chest x-ray and fluoroscopy..
71035...................... Chest x-ray..................
71100...................... X-ray exam of ribs...........
71101...................... X-ray exam of ribs/chest.....
71110...................... X-ray exam of ribs...........
71111...................... X-ray exam of ribs/chest.....
71120...................... X-ray exam of breastbone.....
71130...................... X-ray exam of breastbone.....
71250...................... Ct thorax w/o dye............
72010...................... X-ray exam of spine..........
72020...................... X-ray exam of spine..........
72040...................... X-ray exam of neck spine.....
72050...................... X-ray exam of neck spine.....
72052...................... X-ray exam of neck spine.....
72069...................... X-ray exam of trunk spine....
72070...................... X-ray exam of thoracic spine.
72072...................... X-ray exam of thoracic spine.
72074...................... X-ray exam of thoracic spine.
72080...................... X-ray exam of trunk spine....
72090...................... X-ray exam of trunk spine....
72100...................... X-ray exam of lower spine....
72110...................... X-ray exam of lower spine....
72114...................... X-ray exam of lower spine....
72120...................... X-ray exam of lower spine....
[[Page 66594]]
72125...................... Ct neck spine w/o dye........
72128...................... Ct chest spine w/o dye.......
72131...................... Ct lumbar spine w/o dye......
72141...................... Mri neck spine w/o dye.......
72146...................... Mri chest spine w/o dye......
72148...................... Mri lumbar spine w/o dye.....
72170...................... X-ray exam of pelvis.........
72190...................... X-ray exam of pelvis.........
72192...................... Ct pelvis w/o dye............
72202...................... X-ray exam sacroiliac joints.
72220...................... X-ray exam of tailbone.......
73000...................... X-ray exam of collar bone....
73010...................... X-ray exam of shoulder blade.
73020...................... X-ray exam of shoulder.......
73030...................... X-ray exam of shoulder.......
73050...................... X-ray exam of shoulders......
73060...................... X-ray exam of humerus........
73070...................... X-ray exam of elbow..........
73080...................... X-ray exam of elbow..........
73090...................... X-ray exam of forearm........
73100...................... X-ray exam of wrist..........
73110...................... X-ray exam of wrist..........
73120...................... X-ray exam of hand...........
73130...................... X-ray exam of hand...........
73140...................... X-ray exam of finger(s)......
73200...................... Ct upper extremity w/o dye...
73218...................... Mri upper extremity w/o dye..
73221...................... Mri joint upr extrem w/o dye.
73510...................... X-ray exam of hip............
73520...................... X-ray exam of hips...........
73540...................... X-ray exam of pelvis & hips..
73550...................... X-ray exam of thigh..........
73560...................... X-ray exam of knee, 1 or 2...
73562...................... X-ray exam of knee, 3........
73564...................... X-ray exam, knee, 4 or more..
73565...................... X-ray exam of knees..........
73590...................... X-ray exam of lower leg......
73600...................... X-ray exam of ankle..........
73610...................... X-ray exam of ankle..........
73620...................... X-ray exam of foot...........
73630...................... X-ray exam of foot...........
73650...................... X-ray exam of heel...........
73660...................... X-ray exam of toe(s).........
73700...................... Ct lower extremity w/o dye...
73718...................... Mri lower extremity w/o dye..
73721...................... Mri jnt of lwr extre w/o dye.
74000...................... X-ray exam of abdomen........
74010...................... X-ray exam of abdomen........
74020...................... X-ray exam of abdomen........
74022...................... X-ray exam series, abdomen...
74150...................... Ct abdomen w/o dye...........
74210...................... Contrast x-ray exam of throat
74220...................... Contrast x-ray, esophagus....
74230...................... Cine/vid x-ray, throat/esoph.
74246...................... Contrast x-ray uppr gi tract.
74247...................... Contrst x-ray uppr gi tract..
74249...................... Contrst x-ray uppr gi tract..
76020...................... X-rays for bone age..........
76040...................... X-rays, bone evaluation......
76061...................... X-rays, bone survey..........
76062...................... X-rays, bone survey..........
76065...................... X-rays, bone evaluation......
76066...................... Joint survey, single view....
76070...................... Ct bone density, axial.......
76071...................... Ct bone density, peripheral..
76075...................... Dxa bone density, axial......
76076...................... Dxa bone density/peripheral..
76077...................... Dxa bone density/v-fracture..
76078...................... Radiographic absorptiometry..
76100...................... X-ray exam of body section...
76400...................... Magnetic image, bone marrow..
76510...................... Ophth us, b & quant a........
76511...................... Ophth us, quant a only.......
76512...................... Ophth us, b w/non-quant a....
76513...................... Echo exam of eye, water bath.
76514...................... Echo exam of eye, thickness..
76516...................... Echo exam of eye.............
76519...................... Echo exam of eye.............
76536...................... Us exam of head and neck.....
76645...................... Us exam, breast(s)...........
76700...................... Us exam, abdom, complete.....
76705...................... Echo exam of abdomen.........
76770...................... Us exam abdo back wall, comp.
76775...................... Us exam abdo back wall, lim..
76778...................... Us exam kidney transplant....
76801...................... Ob us < 14 wks, single fetus.
76805...................... Ob us >/= 14 wks, sngl fetus.
76811...................... Ob us, detailed, sngl fetus..
76816...................... Ob us, follow-up, per fetus..
76817...................... Transvaginal us, obstetric...
76830...................... Transvaginal us, non-ob......
76856...................... Us exam, pelvic, complete....
76857...................... Us exam, pelvic, limited.....
76870...................... Us exam, scrotum.............
76880...................... Us exam, extremity...........
76970...................... Ultrasound exam follow-up....
76977...................... Us bone density measure......
76999...................... Echo examination procedure...
77280...................... Set radiation therapy field.. *
77285...................... Set radiation therapy field.. *
77290...................... Set radiation therapy field.. *
77295...................... Set radiation therapy field.. *
77300...................... Radiation therapy dose plan..
[[Page 66595]]
77301...................... Radiotherapy dose plan, imrt.
77315...................... Teletx isodose plan complex..
77326...................... Brachytx isodose calc simp...
77327...................... Brachytx isodose calc interm.
77328...................... Brachytx isodose plan compl..
77331...................... Special radiation dosimetry..
77332...................... Radiation treatment aid(s)... *
77333...................... Radiation treatment aid(s)... *
77334...................... Radiation treatment aid(s)... *
77336...................... Radiation physics consult....
77370...................... Radiation physics consult....
77401...................... Radiation treatment delivery.
77402...................... Radiation treatment delivery.
77403...................... Radiation treatment delivery.
77404...................... Radiation treatment delivery.
77407...................... Radiation treatment delivery.
77408...................... Radiation treatment delivery.
77409...................... Radiation treatment delivery.
77411...................... Radiation treatment delivery.
77412...................... Radiation treatment delivery.
77413...................... Radiation treatment delivery.
77414...................... Radiation treatment delivery.
77416...................... Radiation treatment delivery.
77418...................... Radiation tx delivery, imrt..
77470...................... Special radiation treatment..
77520...................... Proton trmt, simple w/o comp.
77523...................... Proton trmt, intermediate....
80500...................... Lab pathology consultation...
80502...................... Lab pathology consultation...
85097...................... Bone marrow interpretation...
86510...................... Histoplasmosis skin test.....
86850...................... RBC antibody screen..........
86870...................... RBC antibody identification..
86880...................... Coombs test, direct..........
86885...................... Coombs test, indirect, qual..
86886...................... Coombs test, indirect, titer.
86890...................... Autologous blood process.....
86900...................... Blood typing, ABO............
86901...................... Blood typing, Rh (D).........
86903...................... Blood typing, antigen screen.
86904...................... Blood typing, patient serum..
86905...................... Blood typing, RBC antigens...
86906...................... Blood typing, Rh phenotype...
86930...................... Frozen blood prep............
86970...................... RBC pretreatment.............
88104...................... Cytopath fl nongyn, smears...
88106...................... Cytopath fl nongyn, filter...
88107...................... Cytopath fl nongyn, sm/fltr..
88108...................... Cytopath, concentrate tech...
88112...................... Cytopath, cell enhance tech..
88160...................... Cytopath smear, other source.
88161...................... Cytopath smear, other source.
88162...................... Cytopath smear, other source.
88172...................... Cytopathology eval of fna....
88173...................... Cytopath eval, fna, report...
88182...................... Cell marker study............
88184...................... Flowcytometry/ tc, 1 marker..
88185...................... Flowcytometry/tc, add-on.....
88300...................... Surgical path, gross.........
88302...................... Tissue exam by pathologist...
88304...................... Tissue exam by pathologist...
88305...................... Tissue exam by pathologist...
88307...................... Tissue exam by pathologist...
88311...................... Decalcify tissue.............
88312...................... Special stains...............
88313...................... Special stains...............
88321...................... Microslide consultation......
88323...................... Microslide consultation......
88325...................... Comprehensive review of data.
88331...................... Path consult intraop, 1 bloc.
88342...................... Immunohistochemistry.........
88346...................... Immunofluorescent study......
88347...................... Immunofluorescent study......
88348...................... Electron microscopy..........
88358...................... Analysis, tumor..............
88360...................... Tumor immunohistochem/manual.
88361...................... Tumor immunohistochem/comput. *
88365...................... Insitu hybridization (fish)..
88368...................... Insitu hybridization, manual.
88399...................... Surgical pathology procedure.
89049...................... Chct for mal hyperthermia....
89230...................... Collect sweat for test.......
89240...................... Pathology lab procedure......
90761...................... Hydrate iv infusion, add-on..
90761...................... Hydrate iv infusion, add-on.. *
90766...................... Ther/proph/dg iv inf, add-on. *
90801...................... Psy dx interview.............
90802...................... Intac psy dx interview.......
90804...................... Psytx, office, 20-30 min.....
90805...................... Psytx, off, 20-30 min w/e&m..
90806...................... Psytx, off, 45-50 min........
90807...................... Psytx, off, 45-50 min w/e&m..
90808...................... Psytx, office, 75-80 min.....
90809...................... Psytx, off, 75-80, w/e&m.....
90810...................... Intac psytx, off, 20-30 min..
90812...................... Intac psytx, off, 45-50 min..
90816...................... Psytx, hosp, 20-30 min.......
90818...................... Psytx, hosp, 45-50 min.......
90826...................... Intac psytx, hosp, 45-50 min. *
90845...................... Psychoanalysis...............
90846...................... Family psytx w/o patient.....
90847...................... Family psytx w/patient.......
[[Page 66596]]
90853...................... Group psychotherapy..........
90857...................... Intac group psytx............
90862...................... Medication management........
92002...................... Eye exam, new patient........
92004...................... Eye exam, new patient........
92012...................... Eye exam established pat.....
92014...................... Eye exam & treatment.........
92020...................... Special eye evaluation.......
92081...................... Visual field examination(s)..
92082...................... Visual field examination(s)..
92083...................... Visual field examination(s)..
92135...................... Ophth dx imaging post seg....
92136...................... Ophthalmic biometry..........
92225...................... Special eye exam, initial....
92226...................... Special eye exam, subsequent.
92230...................... Eye exam with photos.........
92240...................... Icg angiography..............
92250...................... Eye exam with photos.........
92275...................... Electroretinography..........
92285...................... Eye photography..............
92286...................... Internal eye photography.....
92520...................... Laryngeal function studies...
92541...................... Spontaneous nystagmus test...
92546...................... Sinusoidal rotational test...
92548...................... Posturography................
92552...................... Pure tone audiometry, air....
92553...................... Audiometry, air & bone.......
92555...................... Speech threshold audiometry..
92556...................... Speech audiometry, complete..
92557...................... Comprehensive hearing test...
92567...................... Tympanometry.................
92582...................... Conditioning play audiometry.
92585...................... Auditor evoke potent, compre.
92603...................... Cochlear implt f/up exam 7 >.
92604...................... Reprogram cochlear implt 7 >.
92626...................... Eval aud rehab status........
93005...................... Electrocardiogram, tracing...
93017...................... Cardiovascular stress test... *
93225...................... ECG monitor/record, 24 hrs...
93226...................... ECG monitor/report, 24 hrs...
93231...................... Ecg monitor/record, 24 hrs...
93232...................... ECG monitor/report, 24 hrs...
93236...................... ECG monitor/report, 24 hrs...
93270...................... ECG recording................
93271...................... Ecg/monitoring and analysis..
93278...................... ECG/signal-averaged..........
93727...................... Analyze ilr system...........
93731...................... Analyze pacemaker system.....
93732...................... Analyze pacemaker system.....
93733...................... Telephone analy, pacemaker...
93734...................... Analyze pacemaker system.....
93735...................... Analyze pacemaker system.....
93736...................... Telephonic analy, pacemaker..
93741...................... Analyze ht pace device sngl..
93742...................... Analyze ht pace device sngl..
93743...................... Analyze ht pace device dual..
93744...................... Analyze ht pace device dual..
93786...................... Ambulatory BP recording......
93788...................... Ambulatory BP analysis.......
93797...................... Cardiac rehab................
93798...................... Cardiac rehab/monitor........
93875...................... Extracranial study...........
93880...................... Extracranial study...........
93882...................... Extracranial study...........
93886...................... Intracranial study...........
93888...................... Intracranial study...........
93922...................... Extremity study..............
93923...................... Extremity study..............
93924...................... Extremity study..............
93925...................... Lower extremity study........
93926...................... Lower extremity study........
93930...................... Upper extremity study........
93931...................... Upper extremity study........
93965...................... Extremity study..............
93970...................... Extremity study..............
93971...................... Extremity study..............
93975...................... Vascular study...............
93976...................... Vascular study...............
93978...................... Vascular study...............
93979...................... Vascular study...............
93990...................... Doppler flow testing.........
94015...................... Patient recorded spirometry..
94690...................... Exhaled air analysis.........
95115...................... Immunotherapy, one injection.
95117...................... Immunotherapy injections.....
95165...................... Antigen therapy services.....
95250...................... Glucose monitoring, cont..... *
95805...................... Multiple sleep latency test..
95806...................... Sleep study, unattended......
95807...................... Sleep study, attended........
95808...................... Polysomnography, 1-3.........
95812...................... Eeg, 41-60 minutes...........
95813...................... Eeg, over 1 hour.............
95816...................... Eeg, awake and drowsy........
95819...................... Eeg, awake and asleep........
95822...................... Eeg, coma or sleep only......
95869...................... Muscle test, thor paraspinal.
95872...................... Muscle test, one fiber....... *
95900...................... Motor nerve conduction test..
95921...................... Autonomic nerv function test.
95925...................... Somatosensory testing........
95926...................... Somatosensory testing........ *
95930...................... Visual evoked potential test.
95950...................... Ambulatory eeg monitoring....
95953...................... EEG monitoring/computer......
95970...................... Analyze neurostim, no prog...
95972...................... Analyze neurostim, complex...
95974...................... Cranial neurostim, complex...
95978...................... Analyze neurostim brain/1h...
96000...................... Motion analysis, video/3d....
96101...................... Psycho testing by psych/phys.
[[Page 66597]]
96111...................... Developmental test, extend...
96116...................... Neurobehavioral status exam..
96118...................... Neuropsych tst by psych/phys.
96119...................... Neuropsych testing by tec....
96150...................... Assess hlth/behave, init.....
96151...................... Assess hlth/behave, subseq...
96152...................... Intervene hlth/behave, indiv.
96153...................... Intervene hlth/behave, group.
96415...................... Chemo, iv infusion, addl hr..
96423...................... Chemo ia infuse each addl hr.
96900...................... Ultraviolet light therapy....
96910...................... Photochemotherapy with UV-B..
96912...................... Photochemotherapy with UV-A..
96913...................... Photochemotherapy, UV-A or B.
96920...................... Laser tx, skin < 250 sq cm...
98925...................... Osteopathic manipulation.....
98926...................... Osteopathic manipulation.....
98927...................... Osteopathic manipulation.....
98940...................... Chiropractic manipulation....
98941...................... Chiropractic manipulation....
98942...................... Chiropractic manipulation....
99204...................... Office/outpatient visit, new.
99212...................... Office/outpatient visit, est.
99213...................... Office/outpatient visit, est.
99214...................... Office/outpatient visit, est.
99241...................... Office consultation..........
99242...................... Office consultation..........
99243...................... Office consultation..........
99244...................... Office consultation..........
99245...................... Office consultation..........
0144T...................... CT heart wo dye; qual calc...
C8951...................... IV inf, tx/dx, each addl hr..
C8955...................... Chemotx adm, IV inf, addl hr.
G0008...................... Admin influenza virus vac....
G0101...................... CA screen; pelvic/breast exam
G0127...................... Trim nail(s).................
G0130...................... Single energy x-ray study....
G0166...................... Extrnl counterpulse, per tx..
G0175...................... OPPS Service,sched team conf.
G0332...................... Preadmin IV immunoglobulin...
G0340...................... Robt lin-radsurg fractx 2-5..
G0344...................... Initial preventive exam......
G0365...................... Vessel mapping hemo access...
G0367...................... EKG tracing for initial prev.
G0376...................... Smoke/tobacco counseling >10.
M0064...................... Visit for drug monitoring....
Q0091...................... Obtaining screen pap smear...
------------------------------------------------------------------------
(2) Exploration of Allocation of Packaged Costs to Separately Paid
Procedure Codes
During its August 23-24, 2006 meeting, the APC Panel recommended
that CMS provide claims analysis of the contributions of packaged costs
(including packaged revenue code charges and charges for packaged HCPCS
codes) to the median cost of each drug administration service. (We
refer readers to Recommendation 28 in the August 23-24, 2006
meeting recommendation summary on the CMS Web site at: http://www.cms.hhs.gov/FACA/05--
AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp#TopOfPage.) In
our continued effort to better understand the multiple claims in order
to extract single bill information from them, we examined the extent to
which the packaging in multiple procedure claims differs from the
packaging in the single procedure claims on which we base the median
costs both in general and more specifically for drug administration
services. We performed this analysis using the claims data on which we
based the CY 2007 OPPS/ASC final rule with comment period. We examined
the amount of packaging in multiple procedure versus single procedure
claims in general and in claims for drug administration services in
particular. We conducted this analysis without taking into account the
proposed packaging approach presented in the CY 2008 OPPS/ASC proposed
rule. However, we did not expect the services newly proposed for
packaged payment to commonly appear with a drug administration service.
Therefore, we believed that the analysis conducted on the CY 2007 final
rule with comment period data was sufficient to inform our development
of the CY 2008 OPPS/ASC proposed rule.
In general, we did not believe that the proportionate amount of
packaged costs in the multiple bills relative to the number of primary
services would be greater than that in the single bills. Our findings
supported our hypothesis. The costs in uncoded revenue codes and HCPCS
codes with a packaged status indicator accounted for 22 percent of
observed costs in the universe of all CY 2005 claims that we used to
model the CY 2007 OPPS (including both the single and multiple
procedure bills). Similarly, the costs in uncoded revenue codes and
HCPCS codes with a packaged status indicator accounted for 18 percent
of the total cost in the subset of CY 2005 single bills that we used to
calculate the median costs on which the relative weights were based.
However, the bypass methodology creates a ``pseudo'' single bill
for all claims for services or items on the bypass list, and these
``pseudo'' single bills have no associated packaging, by definition of
the application of the bypass list. Excluding the total cost associated
with bypass codes, 28 percent of observed costs in the single bills
were attributable to packaged services, and 29 percent of observed
costs across all claims were attributable to packaged services.
Therefore, we concluded that, in general, the extent of packaging in
all bills was similar to the amount of packaging in the single
procedure bills we used to set median costs for most APCs.
In the CY 2008 proposed rule (72 FR 42640), we recognized that
aggregate numbers do not address the packaging associated with single
and multiple procedure claims for specific services. In past years, we
received comments stating that the amount of packaging in the single
bills for drug administration services was not representative of the
typical packaged costs of these drug administration services, which
were usually performed in combination with one another, because the
single bills represented less complex and less resource-intensive
services than the usual cases.
We published a study in the CY 2007 OPPS/ASC final rule with
comment period (71 FR 68120 through 68121) that discussed the amount of
packaging on
[[Page 66598]]
the single bills for drug administration procedure codes, and we
promised to replicate that study for the APC Panel. We discussed the
results of this study with the APC Panel at its March 2007 meeting, in
accordance with the APC Panel's August 2006 recommendation and also
published the results in the CY 2008 OPPS/ASC proposed rule (72 FR
42640 through 42641).
As discussed in the proposed rule, we found that drug
administration services demonstrated reasonable single bill
representation in comparison with other OPPS services. Single bills for
drug administration constituted, roughly, 30 percent of all observed
occurrences of drug administration services, varying by code from 7 to
55 percent. The study also demonstrated that packaged costs
substantially contributed to median cost estimates for the majority of
drug administration HCPCS codes (72 FR 42640 through 42641).
For all single bills for CPT code 90780 (Intravenous infusion for
therapy/diagnosis, administered by physician or under direct
supervision of physician; up to one hour), on average, packaged costs
were 31 percent of total cost (median 27 percent). For the same code,
packaged drug and pharmacy costs comprised, on average, 23 percent of
total costs (median 15 percent). Single bills made up 34 percent of all
line-item occurrences of the service, suggesting that this single bill
median cost was fairly robust and probably captured packaging
adequately. On the other hand, CPT code 90784 (Therapeutic,
prophylactic or diagnostic injection (specify material injected);
subcutaneous or intramuscular) demonstrated limited packaging (median 0
percent and mean 17 percent), and the median cost for the code was
derived from only 7 percent of all occurrences of the code. Across all
drug administration codes, over half showed significant median packaged
costs largely attributable to packaged drug and pharmacy costs.
By definition, we were unable to precisely assess the amount of
packaging associated with drug administration codes in the multiple
bills. As a proxy, we estimated packaging as a percent of total cost on
each claim for two subsets of claims. Both analyses suggested the
presence of moderate packaged costs, especially drug and pharmacy
costs, associated with drug administration services in the multiple
bills. We calculated measures of central tendency for packaging
percentages in the multiple bills or portions of multiple bills
remaining after ``pseudo'' singles were created. We referred to this
group of the multiple bills as the ``hardcore'' multiple bills. For the
first subset of ``hardcore'' multiple bills with only drug
administration codes, that is, where multiple drug administration codes
were the only separately paid procedure codes on the claim, we
estimated that packaged costs were 22 percent of total costs (27
percent, on average), where total costs consisted of costs for all
payable codes. Costs for packaged drug HCPCS codes and pharmacy revenue
codes comprised 13 percent of total cost at the median (19 percent, on
average). For the second subset of ``hardcore'' multiple bills with any
drug administration code, that is, where a drug administration code
appeared with other payable codes (largely radiology services and
visits), we estimated packaged costs were 13 percent of total cost at
the median (19 percent, on average). Costs for packaged drugs and
pharmacy revenue codes comprised 6 percent of total cost at the median
(10 percent, on average). The amount of packaging in both proxy
measures, but especially the first subset, closely resembled the
packaged costs as a percentage of drug administration costs observed in
the single bills for drug administration services. While finding a way
to accurately use data from the ``hardcore'' multiple bills to estimate
drug administration median costs undoubtedly would impact medians,
these comparisons suggested that the multiple bill data probably would
support current median estimates.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42641), we noted that
we had received several comments over the past few years offering
algorithms for packaging the costs associated with specific revenue
codes or packaging drugs with certain drug administration codes.
Because of the complexity of even routine OPPS claims, prior research
suggested that such algorithms have limited power to generate
additional single bill claims and do little to change median cost
estimates. In the proposed rule (72 FR 42641), we explained that we
continue to look for simple, but powerful, methodologies like the
bypass list and packaging of HCPCS codes for additional ancillary and
supportive services to assign packaged costs to all services within the
``hardcore'' multiple bills. Ideally, these methodologies should be
intuitive to the provider community, easily integrated into the
complexity of OPPS median cost estimation, and simple to maintain from
year to year. We specifically solicited methodologies for creation of
single bills that meet these criteria.
We received several public comments with regard to the use of data
from single and multiple procedure claims for ratesetting. A summary of
the public comments and our responses follow.
Comment: Several commenters expressed appreciation for CMS'
analysis of packaged costs included on single and multiple procedure
claims for drug administration services. One commenter encouraged CMS
to further analyze the total amount and percentage of packaged costs
associated with all packaged HCPCS codes, as well as other packaged
services reported by hospitals, and examine this information on single
versus multiple procedure claims in order to increase hospitals'
understanding of the actual packaged costs used in the ratesetting
process. Once again, several commenters encouraged CMS to consider
specific packaging algorithms to allocate packaged costs on multiple
procedures claims, in order to create additional ``pseudo'' single
claims for ratesetting.
Response: The packaging of associated costs into payment for major
procedures is a longstanding principle of the OPPS. The OPPS packages
payment for the operating and capital-related costs that are directly
related and integral to furnishing a service on an outpatient basis.
These packaged costs have historically included costs related to use of
an operating or treatment room, anesthesia, medical supplies,
implantable devices, inexpensive drugs, etc. Our findings related to
the packaged costs on single and multiple claims for drug
administration services confirm that the packaging on the single bills
used for ratesetting resembles the drug and pharmacy-related packaged
costs on multiple procedure claims. The packaging associated with drug
administration services on single and multiple claims has historically
been of particular concern to the public, so we are reassured by this
finding. We are not convinced that developing this information for all
other HCPCS codes would provide further useful information to
hospitals. Instead, we prefer to direct our analytic resources toward
exploring additional approaches to using more cost data from multiple
procedure claims for ratesetting. If we are eventually able to use all
OPPS claims in developing median costs, then all packaged costs on
claims would also be incorporated in ratesetting under the OPPS. We
remind hospitals that they should continue to take into consideration
all costs associated with providing HOPD services in establishing their
charges for the services. In addition, hospitals should report packaged
HCPCS codes and charges, consistent with all CPT, OPPS, and local
[[Page 66599]]
contractor instructions, whenever those services are provided to ensure
that the associated costs are included in ratesetting for the major
services.
As we have stated previously regarding our exploration of specific
packaging algorithms, we have found that these approaches, while
resource-intensive on our part, have limited power to generate
additional single bill claims and do little to change median cost
estimates. We received no other specific suggestions for other
approaches to allocating packaged costs on ``hardcore'' multiple bills
that would be intuitive to the provider community, easily integrated
into the complexity of OPPS median cost estimation, and simple to
maintain from year to year. We will continue to explore these data
challenges with the assistance of the Data Subcommittee of the APC
Panel. We believe that further progression toward encounter-based or
episode-based payment for commonly provided combinations of services
could reduce the number of these multiple claims and incorporate
additional claims data, as discussed in section II.A.4.d. of this final
rule with comment period regarding low dose rate prostate brachytherapy
and cardiac electrophysiologic evaluation and ablation procedures.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal for the use of single and multiple
procedure claims for ratesetting. We will continue to pursue additional
methodologies that would allow use of cost data from ``hardcore''
multiple claims for ratesetting.
c. Calculation of CCRs
We calculated hospital-specific overall CCRs and hospital-specific
departmental CCRs for each hospital for which we had claims data in the
period of claims being used to calculate the median costs that we
converted to scaled relative weights for purposes of setting the OPPS
payment rates. We applied the hospital-specific CCR to the hospital's
charges at the most detailed level possible, based on a revenue code to
cost center crosswalk that contains a hierarchy of CCRs used to
estimate costs from charges for each revenue code. That crosswalk is
available for review and continuous comment on the CMS Web site at:
http://www.cms.hhs.gov/HospitalOutpatientPPS/03--
crosswalk.asp#TopOfPage. We calculated CCRs for the standard and
nonstandard cost centers accepted by the electronic cost report
database. In general, the most detailed level at which we calculated
CCRs was the hospital-specific departmental level.
Following the expiration of most medical devices from pass-through
status in CY 2003, prior to which devices were paid at charges reduced
to cost using the hospital's overall CCR, we received comments that our
OPPS cost estimates for device implantation procedures systematically
underestimate the cost of the devices included in the packaged payment
for the procedures because hospitals routinely mark up charges for low
cost items to a much greater extent than they mark up high cost items,
and that these items are often combined in a single cost center on
their Medicare cost report. This is commonly known as ``charge
compression.''
In CY 2006, the device industry commissioned a study to interpolate
a device specific CCR from the medical supply CCR, using publicly
available hospital claims and Medicare cost report data rather than
proprietary data on device costs. After reviewing the device industry's
data analysis and study model, CMS contracted with RTI International
(RTI) to study the impact of charge compression on the cost-based
weight methodology adopted in the FY 2007 IPPS final rule, to evaluate
this model, and to propose solutions. For more information, interested
individuals can view RTI's report on the CMS Web site at: http://www.cms.hhs.gov/reports/downloads/Dalton.pdf.
Any study of cost estimation in general, and charge compression
specifically, has obvious importance for both the OPPS and the IPPS.
RTI's research explicitly focused on the IPPS for several reasons,
which include greater Medicare expenditures under the IPPS, a desire to
evaluate the model quickly given IPPS regulation deadlines, and a focus
on other components of the new FY 2007 IPPS cost-based weight
methodology (CMS Contract No. 500-00-0024-T012, ``A Study of Charge
Compression in Calculating DRG Relative Weights,'' page 5). The study
first addressed the possibility of cross-aggregation bias in the CCRs
used to estimate costs under the IPPS created by the IPPS methodology
of aggregating cost centers into larger departments before calculating
CCRs. The report also addressed potential bias created by estimating
costs using a CCR that reflects the combined costs and charges of
services with wide variation in the amount of hospital markup. In its
assessment of the latter, RTI targeted its attempt to identify the
presence of charge compression to those cost centers presumably
associated with revenue codes demonstrating significant IPPS
expenditures and utilization. RTI assessed the correlation between cost
report CCRs and the percent of charges in a cost center attributable to
a set of similar services represented by a group of revenue codes. RTI
did not examine the correlation between CCRs and revenue codes without
significant IPPS expenditures or a demonstrated concentration in a
specific Diagnosis Related Group (DRG). For example, RTI did not
examine revenue code groups within the pharmacy cost center with low
proportionate inpatient charges that might be important to the OPPS,
such as ``Pharmacy Incident to Radiology.'' RTI states this limitation
in its study and specifically recommends that disaggregated CCRs be
reestimated for hospital outpatient charges.
Cost report CCRs combine both inpatient and outpatient services.
Ideally, RTI would be able to examine the correlation between CCRs for
Medicare inpatient services and inpatient claim charges and the
correlation between CCRs for Medicare outpatient services and
outpatient claim charges. However, the comprehensive nature of the cost
report CCR (which combines inpatient and outpatient services) argues
for an analysis of the correlation between CCRs and combined inpatient
and outpatient claim charges. As noted, the RTI study accepted some
measurement error in its analysis by matching an ``all charges'' CCR to
inpatient estimates of charges for groups of similar services
represented by revenue codes because of short timelines and because
inpatient costs dominate outpatient costs in many ancillary cost
centers. We believe that CCR adjustments used to calculate payment
should be based on the comparison of cost report CCRs to combined
inpatient and outpatient charges. An ``all charges'' model would reduce
measurement error and estimate adjustments to disaggregated CCRs that
could be used in both hospital inpatient and outpatient payment
systems.
RTI made several short-term recommendations for improving the
accuracy of DRG weight estimates from a cost-based methodology to
address bias in combining cost centers and charge compression that
could be considered in the context of OPPS policy. We discussed each
recommendation within the context of the OPPS and provided our
assessment of its application to the OPPS in the CY 2008 OPPS/ASC
proposed rule (72 FR 42642). Of the four short term recommendations, we
believe that only the recommendation to establish regression based
estimates as a
[[Page 66600]]
temporary or permanent method for disaggregating national average CCRs
for medical supplies, drugs, and radiology services under the IPPS has
specific application to the OPPS (RTI study, pages 11 and 86).
Moreover, with regard to radiology services, the OPPS already has
partially implemented RTI's recommendation to use lower CCRs to
estimate costs for those OPPS services allocated to MRI or CT Scan cost
centers through its use of hospital-specific CCRs for nonstandard cost
centers.
For reasons discussed below and in more detail in the proposed rule
(72 FR 42642 through 42643), we proposed to develop an all charges
model that would compare variation in CCRs with variation in combined
inpatient and outpatient charges for sets of similar services and
establish disaggregated regression-based CCRs that could be applied to
both inpatient and outpatient charges. We proposed to evaluate the
results of that methodology for purposes of determining whether the
resulting regression-based CCRs should be proposed for use in
developing the CY 2009 OPPS payment rates. As noted in the proposed
rule (72 FR 42642), the revised all charges model and resulting
regression-based CCRs were not available in time for use in developing
this final rule with comment period.
Since publication of the proposed rule, we have contracted with RTI
to determine whether the statistical model that RTI recommended in its
January 2007 report for adjusting CCRs in inpatient cost computations
can be expanded to include cost computations for significant categories
of outpatient services that are paid under the OPPS and to assess the
impact of any such changes on payment under the OPPS (HHSM 500-2005-
00029I Task Order 0008, ``Refining Cost-to-Charge Ratios for
Calculating APC and DRG Relative Payment Weights''). Under this task
order, RTI will assess the validity of the revenue code-to-cost center
crosswalk used under the OPPS by comparing revenue code and cost center
charges, make recommendations for changes to the crosswalk, and assess
the OPPS use of nonstandard cost centers. RTI will estimate regression-
based CCRs using charge data from both inpatient and outpatient claims
for hospital ancillary departments. RTI will extend its recommended
models to estimate regression-based CCRs for cost centers that are
particularly relevant to APCs, working with CMS staff to analyze the
sensitivity of APC weights to proposed adjustments. RTI also will
convene a technical expert panel to review analyses, as it did for its
first study.
There are several reasons why we did not propose to use the
intradepartmental regression-based CCRs that RTI estimated using IPPS
charges for the CY 2008 OPPS estimation of median costs. We agree with
RTI that the intradepartmental CCRs calculated for the IPPS would not
always be appropriate for application to the OPPS (RTI study, pages 34
and 35). While RTI recommends that the model be recalibrated for
outpatient charges before it is applied to the OPPS, we believed that
the combined nature of the CCRs available from the cost report prevents
an accurate outpatient recalibration that would be appropriate for the
OPPS alone. Therefore, we believed that an all charges model examining
an expanded subset of revenue codes would be the most appropriate, and
that this model should be developed before we could apply the resulting
regression based CCRs to the charges for supplies paid under the OPPS.
Moreover, we were concerned that implementing the regression-based
IPPS related CCRs in the OPPS that RTI estimated for CY 2008 could
result in greater instability in relative payment weights for CY 2008
than would otherwise occur, and that a subsequent change to application
of the regression-based CCRs resulting from development of an all
charges model might also result in significant fluctuations in median
costs and increased instability in payments from CY 2008 to CY 2009.
Therefore, these sequential changes could result in significant
increases in median costs in one year and significant declines in
median costs in the next year.
Therefore, we did not propose to adopt the RTI regression-based
CCRs under the CY 2008 OPPS. As indicated in the proposed rule (72 FR
42643), we stated that we would consider whether it would be
appropriate to adopt regression-based CCRs for the OPPS after we
received RTI's comprehensive review of the OPPS cost estimation
methodology and reviewed the results of the use of both inpatient and
outpatient charges across all payers to reestimate regression-based
CCRs.
We received many public comments on the issue of application of the
disaggregated CCRs that RTI estimated using regression analysis to
calculate payments for the CY 2008 OPPS. A summary of the public
comments and our responses follow.
Comment: The commenters made a number of requests for the CY 2008
OPPS. Some commenters asked specifically that CMS use the RTI
regression-based CCRs to calculate the costs of devices, implants, and
drugs under the CY 2008 OPPS. Other commenters urged CMS not to apply
this charge compression adjustment methodology to diagnostic radiology
services because the application of the methodology to these capital
intensive procedures has not been fully validated and would benefit
from additional analysis. The commenters who supported the application
of the adjustment methodology for CY 2008 asserted that CMS should
disregard the fact that the estimated regression-based CCRs were
calculated using only inpatient charge data because the commenters had
found that using inpatient or outpatient charges yielded similar CCR
estimates for implantable devices and all other supplies. These
commenters believed that CMS should accept the RTI findings that were
based on inpatient charges alone and apply them to the calculation of
median costs for all OPPS weights. They explained that CMS could
consider further refinements to the methodology in future years, such
as estimating the regression-based CCRs using either outpatient or
combined charges, but that CMS should not delay implementing this
important change as it evaluates an all charges model.
Some commenters who supported the application of the adjustment for
CY 2008 also stated that the most glaring cases of charge compression
occur with high cost implantable devices that are reported by hospitals
with low cost supplies in the same supply cost center. They asserted
that the need for analysis of the extent of a problem in other cost
centers should not stop CMS from applying the estimated regression-
based CCRs for CY 2008 to charges for medical supplies, drugs, and
radiology services. One commenter submitted a set of revised weights
for all APCs reflecting regression-based CCRs for implantable devices
and all other supplies, as well as its assumptions in developing the
weights, and asked that CMS review the results. Some commenters stated
that if CMS decides not to implement the RTI recommendations for
regression-based CCRs for CY 2008, it should ensure that an all charges
model is implemented in both the IPPS and the OPPS for CY 2009 through
a joint IPPS/OPPS task force. Some commenters believed that CMS should
either implement the regression-based adjustments in CY 2008 or begin a
transition to them over a period of 2 to 3 years.
The MedPAC recommended that CMS use the RTI's estimated
disaggregated, regression-based CCRs for medical supplies, drugs, and
radiology as part of the OPPS ratesetting process for CY
[[Page 66601]]
2008. It stated that, although the application of the regression based
CCR estimates is not a perfect solution to the problem of charge
compression, the possibility of payment inaccuracies is sufficiently
serious that CMS should implement this imperfect solution. The MedPAC
also recommended that if CMS prefers to await the results of the all
charges model and chooses not to correct for the effects of charge
compression under the CY 2008 OPPS, CMS must do so for the CY 2009
OPPS.
Response: While the RTI recommendations for regression-based CCRs
may have the potential to address issues of charge compression raised
in the public comments about OPPS cost-based weights, we are not
sufficiently convinced that we should adopt the regression-based CCR
estimates for the CY 2008 OPPS from the January 2007 RTI short-term
recommendations for several reasons. First, the focus of the RTI study
on inpatient charges did more than just restrict the regression model
dependent variables to inpatient percentages. The study also limited
the cost centers addressed to those where the inpatient charges
comprised a significant portion of the cost center charges and
substantially contributed to the DRGs. The RTI analysis did not examine
cost centers that have a much greater proportion of outpatient charges,
and as such, are particularly important to APC weights, while also
potentially having a residual import for DRG weight calculations as
well.
Second, adoption of regression-based CCRs in this final rule with
comment period would produce significant changes to the proposed APC
payment rates beyond those already introduced with our CY 2008
packaging approach. The lengthy discussion of public comments to our
proposed packaging approach in section II.A.4. of this final rule with
comment period reflects the public concern raised by a modest change in
the methodology for estimating APC relative weights. Disaggregating
drug and supply cost centers clearly would redistribute hospitals'
resource costs among relative weights for different APCs. Estimated APC
median costs calculated using regression-based CCRs for implantable
devices and all other supplies, which were furnished by one commenter,
showed increases for some services of as high as 28 percent, such as
APC 0418 (Insertion of Left Ventricular Lead). Others would decline by
as much as 11 percent, including APC 0674 (Prostate Cryoablation) and
APC 0086 (Level III Electrophysiologic Procedures). An adjusted ``all
other supply'' CCR would reduce the median cost of any service with
significant supply packaging. Adoption of regression-based CCRs could
interact with other potential changes to the APC payment groups under
the OPPS. Budget neutrality adjustments could further increase the
magnitude of these observed differences. We believe that these
significant redistributional effects would have to be confirmed through
CMS analysis, modeled, and made available for public comment should CMS
decide to adopt regression-based CCRs.
Third, we anticipate overall changes to our cost estimation
methodology in the future, including changes to the revenue code-to-
cost center crosswalk and use of nonstandard cost centers. We believe
that a comprehensive review of cost estimation is an appropriate time
to explore the potential use of disaggregated CCRs for the OPPS. For
example, if we implemented only select regression-based CCRs or
crosswalk refinements, we could inappropriately redistribute weight
within the system.
Finally, as noted in the FY 2008 IPPS final rule (72 FR 47192
through 47200), despite commenters' support for the disaggregated CCRs
developed from regression analysis, we remain concerned about the
accuracy of using regression-based estimates to determine relative
weights rather than the Medicare cost report. This is especially true
for the OPPS, given the potential redistribution of resource costs
among services. One commenter noted that poor capital allocation to MRI
and CT Scan revenue code charges could explain the observed differences
in CCRs for these services, and a regression-based adjustment based on
incorrect capital allocation would be equally inaccurate. As discussed
in the FY 2008 IPPS final rule (72 FR 47196), we fully support
voluntary educational initiatives to improve uniformity in reporting
costs and charges on the cost report. Participation in these
educational initiatives by hospitals is voluntary. Hospitals are not
required to change how they report costs and charges if their current
cost reporting practices are consistent with rules and regulations and
applicable instructions. However, both the IPPS and OPPS relative
weight estimates will benefit from any steps taken to improve cost
reporting. To the extent allowed under current regulations and cost
report instructions, we encourage hospitals to report costs and charges
consistently with how the data are used to determine relative weights.
We believe this goal is of mutual benefit to both Medicare and
hospitals.
In conclusion, we believe that it is important that the initial RTI
estimation of regression-based CCRs be replicated with the inclusion of
hospital outpatient charges, that the study examine the current OPPS
revenue code-to-cost center crosswalk and the use of nonstandard cost
centers, and that the analysis focus on the cost centers that have
significant hospital outpatient charges. Regression-based CCRs may have
potential to address issues of charge compression under the OPPS and
possible mismatches between how costs and charges are reported in the
cost reports and on OPPS claims. However, given the potential resulting
change in APC weights and redistributional impact, we believe we would
need to apply regression-based CCRs in all areas eligible for an
adjustment, as well as implement appropriate crosswalk refinements, in
order to not under-or overvalue relative weights within the system. We
continue to have concerns about premature adoption of regression-based
CCRs without the benefit of knowing how they would interact with other
APC changes. We further believe that such methodological changes would
need to be proposed, including presentation of our assessment of the
possible impact of the methodology and solicitation of public comment.
Once we have received the results of RTI's evaluation, we will analyze
the findings and then consider whether it could be appropriate to
propose to use regression-based CCRs under the OPPS. Once we have
completed our analysis, we will then examine whether the educational
activities being undertaken by the hospital community to improve cost
reporting accuracy under the IPPS would help to mitigate charge
compression under the OPPS, either as an adjunct to the application of
regression-based CCRs or in lieu of such an adjustment. After the
conclusion of our analysis of the RTI evaluation and our review of
hospital educational activities, we will then determine whether any
refinements should be proposed.
Comment: One commenter indicated that the standard hospital
accounting methodology for treatment of high capital costs, including
the costs of expensive nonmovable radiology equipment, results in CCRs
for radiology services that understate the true costs of radiology
services because the high capital costs are spread over all departments
of the hospital on a square footage basis. The commenter argued that
this understatement of the costs in the CCR for radiology-related
[[Page 66602]]
departments results in calculated costs for radiology services that are
too low because flawed CCRs are applied to the charges for the services
provided by the radiology department.
Response: We will consider the issue as part of our assessment of
CCRs over the upcoming year, in the context of the RTI study as
described earlier and the ongoing work that the hospital industry is
undertaking with respect to cost reporting.
2. Calculation of Median Costs
In this section of this final rule with comment period, we discuss
the use of claims to calculate the final OPPS payment rates for CY
2008. The hospital OPPS 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 on the CMS Web site at:
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 2008
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.'' These files are available for both the claims
that were used to calculate the proposed payment rates for the CY 2008
OPPS and also for the claims that were used to calculate the final
payment rates for the CY 2008 OPPS.
As proposed, we used the following methodology to establish the
relative weights used in calculating the OPPS payment rates for CY 2008
shown in Addenda A and B to this final rule with comment period. This
methodology is as follows:
a. Claims Preparation
We used hospital outpatient claims for the full CY 2006, processed
before June 30, 2007, to set the final relative weights for CY 2008. To
begin the calculation of the relative weights for CY 2008, we pulled
all claims for outpatient services furnished in CY 2006 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 would 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, the U.S. Virgin Islands, American
Samoa, and the Northern Mariana Islands 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 108 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 2007, using the
revised CCR calculation which excluded the costs of paramedical
education programs and weighted the outpatient charges by the volume of
outpatient services furnished by the hospital. We refer readers to the
CY 2007 OPPS/ASC final rule with comment period for more information
(71 FR 67983 through 67985). We first limited the population of cost
reports to only those for hospitals that filed outpatient claims in CY
2006 before determining whether the CCRs for such hospitals were valid.
We then calculated the CCRs for each cost center and the overall
CCR 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 2005. As proposed, for this final rule
with comment period, we used the most recently submitted cost reports
to calculate the CCRs to be used to calculate median costs for the CY
2008 OPPS rates. 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 section II.A.1.c. of this final rule with
comment period for all purposes that required 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 hospitals with obviously erroneous CCRs
(greater than 90 or less than .0001); and those from hospitals with
overall 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 (that is, departmental) level by
removing the CCRs for each cost center as outliers if they exceeded +/-
3 standard deviations from the geometric mean. 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 cost
center 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 on 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
4 of the proposed rule contained a list of the revenue codes we
proposed to package. Revenue codes not included in Table 4 were those
not allowed under the OPPS because their services could not be paid
under the OPPS (for example, inpatient room and
[[Page 66603]]
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
final rule with comment period.
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, the U.S. Virgin Islands, American Samoa, and the
Northern Mariana Islands 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 moved to another
file claims that contained nothing but influenza and pneumococcal
pneumonia (``PPV'') vaccines. Influenza and PPV vaccines are paid at
reasonable cost and, therefore, these claims are not used to set OPPS
rates. We note that the separate file containing partial
hospitalization claims is included in the files that are available for
purchase as discussed above. Unlike years past, we did not create a
separate file of claims containing observation services because we are
packaging all observation care for the CY 2008 OPPS.
We next copied line-item costs for drugs, blood, and brachytherapy
sources (the lines stay on the claim, but are copied 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 brachytherapy
sources, as well as other information used to set payment rates, such
as a unit-to-day ratio for drugs.
b. Splitting Claims and Creation of ``Pseudo'' Single Claims.
We then split the claims into five groups: single majors, multiple
majors, single minors, multiple minors, and other claims. (Specific
definitions of these groups follow below.) In years prior to the CY
2007 OPPS, we made a determination about 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 the five
groups identified above. For the CY 2007 OPPS, we used status
indicators to sort the claims into these groups. We defined major
procedures as any procedure having a status indicator of ``S,'' ``T,''
``V,'' or ``X;'' defined minor procedures as any code having a status
indicator of ``N;'' and classified ``other'' procedures as any code
having a status indicator other than ``S,'' ``T,'' ``V,'' ``X,'' or
``N.'' For the CY 2007 OPPS proposed rule limited data set and
identifiable data set, these definitions excluded claims on which
hospitals billed drugs and devices without also reporting separately
paid procedure codes and, therefore, those public use files did not
contain all claims used to calculate the drug and device frequencies
and medians. We corrected this for the CY 2007 OPPS/ASC final rule with
comment period limited data set and identifiable data set by extracting
claims containing drugs and devices from the set of ``other'' claims
and adding them to the public use files.
At its March 2007 meeting, the APC Panel recommended that CMS edit
and return for correction claims that contain a HCPCS code for a
separately paid drug or device but that also do not contain a HCPCS
code assigned to a procedural APC (that is, those not assigned status
indicator ``S,'' ``T,'' ``V,'' or ``X''). The APC Panel stated that
this edit should improve the claims data and may increase the number of
single bills available for ratesetting. We noted that such an edit
would be broader than the device-to-procedure code edits we implemented
for CY 2007 for selected devices, and we solicited comments on the
impact of establishing such edits on hospital billing processes and
related potential improvements to claims data. In the CY 2008 proposed
rule (72 FR 42645), we explained that in view of the prior public
comments and our desire to ensure that the public data files contained
all appropriate data, for the CY 2008 OPPS, we proposed to define
majors as HCPCS codes that have a status indicator of ``S,'' ``T,''
``V,'' or ``X.'' We proposed to define minors as HCPCS codes that have
a status indicator of ``F,'' ``G,'' ``H,'' ``K,'' ``L,'' or ``N'' but,
as discussed above, to make single bills out of any claims for single
procedures with a minor code that also has an APC assignment. This
ensured that the claims that contained only HCPCS codes for drugs and
biologicals or devices but that did not contain codes for procedures
were included in the limited data set and the identifiable data set. It
also ensured that conditionally packaged services proposed to receive
separate payment only when they were billed without any other
separately payable OPPS services would be treated appropriately for
purposes of median cost calculations. We proposed to define ``other''
services as HCPCS codes that had a status indicator other than those
defined as majors or minors.
We received several public comments regarding our proposal to
continue to process OPPS claims for a separately paid drug or device
that did not also report a procedural HCPCS code with a status
indicator of ``S,'' ``T,'' ``V,'' or ``X.'' A summary of the public
comments and our responses follow.
Comment: Several commenters requested that we adopt the
recommendation of the APC Panel that CMS edit and return for correction
claims that contained a HCPCS code for a separately paid drug or device
but that did not also report a HCPCS code with a status indicator of
``S,'' ``T,'' ``V,'' or ``X.'' These commenters believed that this
process would generally improve hospitals' coding and charging
practices. One commenter indicated that, under some circumstances, a
hospital may bill for a diagnostic radiopharmaceutical that is
administered on one day but may not report the associated nuclear
medicine procedure on the same claim because the procedure would be
provided several days later. In this case, the bill for the diagnostic
radiopharmaceutical would include no other services with a status
indicator of ``S,'' ``T,'' ``V,'' or ``X'' because the administration
of the radiopharmaceutical would be considered to be a part of the
nuclear medicine study.
Response: We have accepted this recommendation in selective
situations. We currently edit claims in the Outpatient Code Editor
(OCE) for selected devices for which our data show that hospitals have
a history of reporting the HCPCS device code but not reporting the
HCPCS procedure code that is necessary for the device to have
therapeutic benefit. See the device-to-procedure edits on the OPPS Web
page at http://www.cms.hhs.gov/HospitalOutpatientPPS/. Moreover, as
discussed in more detail in section II.A.4.c.(5) of this final rule
with comment period, effective for dates of service on or after January
1, 2008, we will implement OCE edits for diagnostic nuclear medicine
services that will require that a HCPCS code for a diagnostic
radiopharmaceutical must be on the claim for the claim to be processed
to payment. Claims will be returned to the provider for correction if
they contain a nuclear medicine service but the hospital does not also
report a radiopharmaceutical on the same claim. We will continue to
assess the need for OCE edits based upon the unique
[[Page 66604]]
circumstances of individual services or categories of services.
In the CY 2008 proposed rule (72 FR 42645), we explained our
continued belief that using status indicators, with the proposed
changes, 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 for analysis and public
comment on the proposed rule.
We used status indicator ``Q'' in Addendum B to the proposed rule
to identify services that would receive separate HCPCS code-specific
payment when specific criteria are met, and payment for the individual
service would be packaged in all other circumstances. We proposed
several different sets of criteria to determine whether separate
payment would be made for specific services. For example, we proposed
that HCPCS code G0379 (Direct admission of patient for hospital
observation care) be assigned status indicator ``Q'' in Addendum B to
the proposed rule because we proposed that it receive separate payment
only if it is billed on the same date of service as HCPCS code G0378
(Hospital observation service, per hour), without any services with
status indicator ``T'' or ``V'' or Critical Care (APC 0617). We also
proposed to assign the specific services in the proposed composite APCs
discussed in section II.A.4.d. of the proposed rule status indicator
``Q'' in Addendum B to the proposed rule because we proposed that their
payment would be bundled into a single composite payment for a
combination of major procedures under certain circumstances. As
proposed, these services would only receive separate code-specific
payment if certain criteria were met. The same is true for those less
intensive outpatient mental health treatment services for which payment
would be limited to the partial hospitalization per diem rate and which
also were assigned status indicator ``Q'' in Addendum B to the proposed
rule. According to longstanding OPPS payment policy (65 FR 18455),
payment for these individual mental health services is bundled into a
single payment, APC 0034 (Mental Health Services Composite), when the
sum of the individual mental health service payments for all of those
mental health services provided on the same day would exceed payment
for a day of partial hospitalization services. However, the largest
number of specific HCPCS codes identified by status indicator ``Q'' in
Addendum B to the proposed rule were those codes that we identified as
``special'' packaged codes, where we proposed that a hospital would
receive separate payment for providing one unit of a service when the
``special'' packaged code appears on the same day on a claim without
another service that was assigned status indicator ``S,'' ``T,'' ``V,''
or ``X.'' We proposed to package payment for these HCPCS codes when the
code appears on the same date of service on a claim with any other
service that was assigned status indicator ``S,'' ``T,'' ``V,'' or
``X.''
In response to public comments as discussed in detail in section
II.A.4. of this final rule with comment period, we refined the proposed
methodology for paying claims that contain ``special'' packaged codes
with status indicator ``Q'' when there is a major separately paid
procedure on the claim for the same date and when there are multiple
``special'' packaged codes with status indicator ``Q'' but no major
procedure on the claim. This last and largest subset of conditionally
packaged services, referred to as ``special'' packaged codes in the
proposed rule, had to be integrated into the identification of single
and multiple bills for ratesetting to ensure that the costs for these
services were appropriately packaged when they appeared with any other
separately paid service or paid separately when appearing by
themselves.
We handled these ``special'' packaged ``Q'' status codes in the
data for this final rule with comment period by assigning the HCPCS
code an APC and a data status indicator of ``N.'' This gives all
special packaged codes an initial status of ``minor'' that is changed,
when appropriate, through the split process. We identified two subsets
of the ``special'' packaged codes for the purpose of payment and
ratesetting. Imaging supervision and interpretation ``special''
packaged codes are now named ``T-packaged'' codes. All other
``special'' packaged codes are referred to as ``STVX-packaged'' codes.
When an ``STVX-packaged'' code appeared with a HCPCS code with a status
indicator of ``S,'' ``T,'' ``V,'' or ``X'' on the same date of service,
it retained its minor status and was treated as a packaged code and
received a status indicator of ``N.'' The costs that appeared on the
lines with these codes were packaged into the cost of the HCPCS code
with a status indicator of ``S,'' ``T,'' ``V,'' or ``X'' in the single
bills and contributed to the median cost for the primary service with
which they appeared. When the ``STVX packaged'' code appeared by
itself, without other special packaged codes on the same claim, and had
a unit of one, we changed the status indicator on the line to the
status indicator of the APC to which the code was assigned, converting
the service from a single minor to a single major. This created
``natural'' single bills for the ``STVX-packaged'' codes. In the case
of multiple ``STVX-packaged'' codes reported on a claim on the same
date of service but without a major separately paid procedure (that is,
``S,'' ``T,'' ``V,'' or ``X''), we first identified the ``STVX-
packaged'' code with the highest CY 2007 OPPS payment weight. We then
changed the status indicator on the line to the status indicator of the
APC to which this particular code was assigned, converting the service
from a single minor to a single major, and we forced the units to be
one to conform with our policy of paying only one unit of a ``Q''
status service. We extracted these claims from the multiple minors to
create ``pseudo'' single bills. We summed all costs on the claim and
associated the resulting cost with the payable ``STVX-packaged'' code
that had the highest CY 2007 OPPS payment weight. We used natural and
``pseudo'' single procedure claims for ``STVX-packaged'' codes to set
the median costs for the APCs to which the codes were assigned when
they would be separately paid.
We modified this methodology for the ``T-packaged'' codes (imaging
supervision and interpretation services in CY 2008) because our final
CY 2008 payment policy for these services differs from the policy for
``STVX-packaged'' codes. Although we treated all ``special'' packaged
codes as ``STVX-packaged'' codes in the proposed rule, in this final
rule with comment period, ``T-packaged'' services are packaged only
when they appear with a service with a status indicator of ``T'' on the
same date; otherwise, ``T packaged'' services are paid separately. We
assessed all claims for the presence of ``T packaged'' services and
determined their final payment disposition, packaged or separately
paid, prior to splitting the claims into single and multiple majors and
minors. When a ``T-packaged'' code appeared with a HCPCS code with a
status indicator of ``T'' on the same date of service, the ``T-
packaged'' code was treated as a packaged code and retained its minor
status and a status indicator of ``N.'' Otherwise, we designated a ``T-
packaged'' service that would be separately paid by identifying the
``T-packaged'' code on the date of service with the highest CY 2007
payment weight. We changed the status indicator on the line of the ``T-
packaged'' code with the highest CY 2007 payment weight to the status
indicator of the APC
[[Page 66605]]
to which the code was assigned, converting it from a single minor to a
single major. We forced the units to be one to conform with our policy
of paying only one unit of a service with a status indicator of ``Q.''
Any remaining ``T-packaged'' codes appearing on the same date of
service retained their minor status and a status indicator of ``N.'' In
the single and ``pseudo'' single bills, the costs that appeared on the
lines with these codes were packaged into the cost of the HCPCS code
with a status indicator of ``T.'' The remaining claims, ``T-packaged''
services on claims with another service with a status indicator of
``S,'' ``V,'' or ``X'' on the same date, became multiple majors. The
bypass process for breaking multiple major claims created additional
``pseudo'' single bills for the ``T-packaged'' codes that had been
converted to major status. When the ``T-packaged'' code appeared by
itself with packaged services and one unit, we changed the status
indicator on the line to the status indicator of the APC to which the
code was assigned, converting the service to a single major procedure.
In the case of multiple ``T-packaged'' codes reported on a claim on the
same date of service but without a major separately paid procedure
(``S,'' ``T,'' ``V,'' or ``X''), we summed all costs on the claim,
associated the resulting cost with the ``T-packaged'' or ``STVX-
packaged'' code that had the highest 2007 OPPS payment weight, and
forced the units to one. We extracted these claims from the multiple
minors to created new single bills. These processes created ``natural''
and ``pseudo'' single bills for the ``T-packaged'' codes that were then
used to set the median cost for each specific code and for the APCs to
which the codes would be assigned when they were separately paid.
We added the logic necessary to deal with these codes as part of
the split of the claims into the five groups defined below and in our
review of the multiple minor claims. We evaluated the ``T-packaged''
codes that had been on the bypass list to see if they might be eligible
for continuation on the list, as these codes would appear with their
final payment disposition in the multiple majors. However, we
determined that none of these codes should be returned to the bypass
list because their associated packaging under their CY 2008 ``Q''
payment status exceeded the empirical criteria designed to limit error
in the allocation of packaged costs through the bypass process.
Specifically, we 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'').
Claims with one unit of a status indicator ``Q'' code that was an
``STVX-packaged'' code or ``T-packaged'' code where there was no code
on the claim with status indicator ``S,'' ``T,'' `` V,'' or ``X,'' or
``T,'' respectively.
2. Multiple Major Claims: Claims with more than one separately
payable procedure (that is, status indicator ``S,'' ``T,'' ``V,'' or
``X''), or multiple units of one payable procedure. As discussed below,
some of these were used in median setting. These claims included those
with a status indicator ``Q'' code that was a ``T-packaged'' code and
no procedure with a status indicator ``T'' on the same date of service.
We also included in this set claims that contained one unit of one code
when the bilateral modifier was appended to the code and the code was
conditionally or independently bilateral. In these cases, the claims
represented more than one unit of the service described by the code,
notwithstanding that only one unit was billed.
3. Single Minor Claims: Claims with a single HCPCS code that was
assigned status indicator ``F,'' ``G,'' ``H,'' ``K,'' ``L,'' or ``N''
and was not an ``STVX-packaged'' or ``T packaged code.''
4. Multiple Minor Claims: Claims with multiple HCPCS codes that
were assigned status indicator ``F,'' ``G,'' ``H,'' ``K,'' ``L,'' or
``N.'' This set included ``STVX packaged'' and ``T-packaged'' codes
with more than one unit of the code or more than one line of these
codes on the same date of service. As noted above, we created
``pseudo'' singles from some of these claims when we broke the claim by
date, packaged the costs into the code with the highest CY 2007 payment
weight, and forced the units to one to match our payment policy of
paying one unit.
5. Non-OPPS Claims: Claims that contained no services payable under
the OPPS (that is, all status indicators other than those listed for
major or minor status). These claims were 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 tests, and do not contain either a code for a separately
paid service or a code for a packaged service.
The claims listed in numbers 1, 2, 3, and 4 above were included in
the data files that can be purchased as described above. ``STVX-
packaged'' and ``T-packaged'' codes appear in the single major file,
the multiple major file, and the multiple minor file.
We set aside the single minor, multiple minor, and non-OPPS claims
(numbers 3, 4, and 5 above) because we did not use these claims in
calculating median costs of procedural APCs. We then used the bypass
codes listed earlier in Table 1 and discussed in section II.A.1.b. of
this final rule with comment period to remove separately payable
procedures that we determined contained limited or no packaged costs or
that 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 list, we
split the claim into two ``pseudo'' single procedure claim 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 code
charges. We then examined the multiple major claims for dates of
service to determine if we could break them into ``pseudo'' 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 dates
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 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 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 single claims even after applying all of
the techniques for creation of ``pseudo'' singles. Among those excluded
were claims that contained codes that were viewed as independently or
conditionally bilateral and that contained the bilateral modifier
(Modifier 50 (Bilateral procedure)) because the line-item cost for the
code represented the cost of two units of the procedure,
notwithstanding that the code appeared with a unit of one. Therefore,
the charge on the line
[[Page 66606]]
represented the charge for two services rather than a single service
and using the line as reported would have overstated the cost of a
single procedure.
c. Completion of Claim Records and Median Cost Calculations
We then packaged the costs of packaged HCPCS codes (codes with
status indicator ``N'' listed in Addendum B to the proposed rule and
the costs of those lines for ``Q'' status services that retained status
indicator ``N'' through the split process as described above) and
packaged revenue codes into the cost of the single major procedure
remaining on the claim.
The final list of packaged revenue codes is shown in Table 2 below.
At its March 2007 meeting, the APC Panel recommended that CMS review
the final list of packaged revenue codes for consistency with OPPS
policy and ensure that future versions of the OCE edit accordingly. We
compared the packaged revenue codes in the OCE to the final list of
packaged revenue codes for the CY 2007 OPPS (71 FR 67989 through 67990)
that we used for packaging costs in median calculation. As a result of
that analysis, we stated in the CY 2008 OPPS/ASC proposed rule (72 RF
42646) that we accepted the APC Panel's recommendation and we proposed
to change the list of packaged revenue codes for the CY 2008 OPPS in
the following manner. First, we proposed to remove revenue codes 0274
(Prosthetic/Orthotic devices) and 0290 (Durable Medical Equipment) from
the list of packaged revenue codes because we do not permit hospitals
to report implantable devices in these revenue codes (Internet Only
Manual 100-4, Chapter 4, section 20.5.1.1). We also specifically
proposed to add revenue code 0273 (Take Home Supplies) to the list of
packaged revenue codes because we believed that the charges under this
revenue code were for the incidental supplies that hospitals sometimes
provided for patients who were discharged at a time when it was not
possible to secure the supplies needed for a brief time at home. We
proposed to conform the list of packaged revenue codes in the OCE to
the OPPS for CY 2008. We made these changes in the calculation of the
CY 2008 OPPS payment rates. The final CY 2008 packaged revenue codes
are displayed in Table 2 below.
We packaged the costs of the HCPCS codes that were shown with
status indicator ``N'' into the cost of the independent service to
which the packaged service was ancillary or supportive. We refer
readers to section II.A.4. of this final rule with comment period for a
more complete discussion of the final packaging changes for CY 2008.
We also excluded (1) claims that had zero costs after summing all
costs on the claim and (2) claims containing packaging flag number 3.
Effective for services furnished on or after July 1, 2004, the OCE
assigned 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 the OPPS) for which the fiscal
intermediary was required to allocate the sum of charges for services
with a status indicator equaling ``S'' or ``T'' based on the weight of
the APC to which each code was assigned. We did not believe that these
charges, which were token charges as submitted by the hospital, were
valid reflections of hospital resources. Therefore, we deleted these
claims. We also deleted claims for which the charges equaled the
revenue center payment (that is, the Medicare payment) on the
assumption that where the charge equaled 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 used
the pre reclassified wage indices for standardization because we
believed that they better reflected the true costs of items and
services in the area in which the hospital was located than the post
reclassification wage indices and, therefore, would result in the most
accurate unadjusted 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).
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, approximately 58 million
claims were left for this final rule comment period. Of these 58
million claims, we were able to use some portion of approximately 54
million whole claims (93 percent of approximately 58 million
potentially usable claims) to create approximately 97 million single
and ``pseudo'' single claims, of which we used 96 million single bills
(after trimming out just over 900,000 claims as discussed below) in the
CY 2008 median development and ratesetting.
We used the remaining claims to calculate the CY 2008 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. 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 where we believed that it was appropriate. Section III.
of this final rule with comment period includes a discussion of certain
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.
In the CY 2008 proposed rule (72 FR 42646), we explained that in
our review of median costs for HCPCS codes and their assigned APCs, we
had frequently noticed that some services were consistently rarely
performed in the hospital outpatient setting for the Medicare
population. In particular, there were a number of services, such as
several procedures related to the care of pregnant women, that had
annual Medicare claims volume of 100 or fewer occurrences. By
definition, these services also had a small number of single bills from
which to estimate median costs. In addition, in some cases, these codes
had been historically assigned to clinical APCs where all the services
were low volume. Therefore, the median costs for these services and
APCs often fluctuated from year to year, in part due to the variability
created by such a small number of claims. One of the benefits of basing
payment on the median cost of many HCPCS codes with sufficient single
bill representation in an APC is that such fluctuation would be
moderated by the increased number of observations for similar services
on
[[Page 66607]]
which the APC median cost was also based. We considered proposing a
distinct methodology for calculation of the median cost of low total
volume APCs in order to provide more stability in payment from year to
year for these low total volume services. However, after examination of
the low total volume OPPS services and their assigned APCs, we
concluded that there were other clinical APCs with higher volumes of
total claims to which these low total volume services could be
reassigned, while ensuring the continued clinical and resource
homogeneity of the clinical APCs to which they would be newly
reassigned. Therefore, we believed that it would be more appropriate to
reconfigure clinical APCs to eliminate most of the low total volume
APCs. We observed that these low volume services differed from other
OPPS services only because they were not often furnished to the
Medicare population. Therefore, we proposed to reconfigure certain
clinical APCs for CY 2008 as a way to promote stability and appropriate
payment for the services assigned to them, including low total volume
services. We believed that these proposed reconfigurations maintained
APC clinical and resource homogeneity. We proposed these changes as an
alternative to developing specific quantitative approaches to treating
low total volume APCs differently for purposes of median calculation.
Specifically, we proposed that 3 APCs (all of which are New Technology
APCs) would have a total volume of services less than 100, and only 17
APCs would have a total volume of less than 1,000, in comparison with
CY 2007 where 9 APCs (including 3 New Technology APCs) had a total
volume of less than 100 and 36 APCs had a total volume of less than
1,000. In this final rule with comment period, 3 APCs (all New
Technology APCs) have a total volume of less than 100 and 15 APCs have
a total volume of less than 1,000.
We received a number of public comments on our proposed process for
calculating the median costs on which our payment rates are based. A
summary of the pubic comments and our responses follow.
Comment: Some commenters objected to the volatility of the OPPS
rates from year to year. The commenters asserted that the absence of
stability in the OPPS rates creates budgeting, planning, and operating
problems for hospitals, and that as more care is provided on an
outpatient, rather than inpatient basis, the need for stable payment
rates from one year to the next becomes more important to hospitals.
Some commenters asked that CMS permit no payment rate to change by more
than 5 percent from one year to the next.
Response: There are a number of factors pertinent to the OPPS that
cause median costs to change from one year to the next. Some of these
are a reflection of hospital behavior, and some of them are a
reflection of fundamental characteristics of the OPPS as defined in
statute. For example, the OPPS payment rates are based on hospital cost
report and claims data. However, hospital costs and charges change each
year and this results in both changes to the CCRs taken from the most
currently available cost reports and also differences in the charges on
the claims that are the basis of the calculation of the median costs on
which OPPS rates are based. Similarly, hospitals adjust their mix of
services from year to year by offering new services and ceasing to
furnish services or changing the proportion of the various services
they furnish, which has impact on the CCRs that we derive from their
cost reports. CMS cannot stabilize these hospital-driven fundamental
inputs to the calculation of OPPS payment rates. Moreover, there are
other essential elements of the OPPS which contribute to the changes in
relative weights each year. These include, but are not limited to,
reassignments of HCPCS codes to APCs to rectify 2 times violations as
required by the law, to address the costs of new services, and to
respond to public comments. Moreover, for some services, we cannot
avoid using small numbers of claims, either because the volume of
services is naturally low or because the claims data do not facilitate
the calculation of a median cost for a single service. Where there are
small numbers of claims to be used in median calculation, there is more
volatility in the median cost from one year to the next. Lastly,
changes to OPPS payment policy (for example, changes to packaging) also
contribute to some extent to the fluctuations in the OPPS payment rates
for the same service from year to year.
We cannot avoid the naturally occurring volatility in the cost
report and claims data that hospitals submit and on which the payment
rates are based. Moreover (with limited exceptions), we are required by
law to reassign HCPCS codes to APCs where it is necessary to avoid 2
times violations. However, we have made other changes to resolve some
of the other potential reasons for instability from year to year.
Specifically, we continue to seek ways to use more claims data so that
we have fewer APCs for which there are small numbers of single bills
used to set the APC median costs. Moreover, we have tried to eliminate
APCs with very small numbers of single bills where we could do so. We
received no public comments that objected to our proposal to eliminate
a number of very low volume APCs; therefore, we are adopting these
reconfigurations for CY 2008. We recognize that changes to payment
policies, such as the packaging of payment for ancillary and supportive
services and the implementation of composite APCs, may contribute to
volatility in payment rates in the short term, but we believe that
larger payment packages and bundles will help to stabilize payments in
future years by enabling us to use more claims data and by establishing
payments for larger groups of services.
Comment: A commenter stated that CMS should crosswalk revenue code
0278 (Other implants, under the Medical/Surgical Supplies category) to
cost center 3540 (Prosthetic Devices), which generally represents
higher cost technology, instead of crosswalking it to cost center 5500
(Medical Supplies Charge to Patient), which often represents lower cost
items. The commenter indicated that this change to the revenue code-to-
cost center crosswalk would result in improved estimates of the costs
of the devices billed under revenue code 0278 and, therefore, would
result in more accurate payments.
Response: We will carefully examine the implications of making this
change in the future. However, for CY 2008 this change would have a
negligible effect on the median costs for services with charges
reported under revenue code 0278. Only 20 providers out of 4,201 in the
file of the 2005-2006 cost reports used cost center 3540.
Comment: Some commenters asked that CMS provide an adjustment for
medical education costs under the OPPS because so much of the costs of
teaching services are being incurred in the HOPD as many of the
services previously furnished only in the inpatient setting are now
being furnished in the HOPD. The commenters stated that CMS indicated
that it would study the costs and payment differential among different
classes of providers in the April 7, 2000 OPPS final rule with comment
period but has not done so. The commenters also asserted that section
4523 of the BBA requires the Secretary to establish adjustments ``as
determined to be necessary to ensure equitable payments * * * for
certain classes of hospitals'' and, therefore, CMS should study whether
the hospital outpatient costs of teaching hospitals are higher than the
costs of other hospitals for purposes of determining whether there
should be a teaching
[[Page 66608]]
hospital adjustment. The commenters explained that their internal
analysis of 2004 Medicare cost reports showed that the average
outpatient margins were -20.2 percent for major teaching hospitals, -
10.1 percent for other teaching hospitals, and -11.8 percent for non-
teaching hospitals. They believed these findings demonstrated that the
hospital outpatient costs of major teaching hospitals are significantly
greater than the costs of other hospitals. The commenters requested
that CMS conduct its own analysis, and added that if that analysis
shows such a difference, CMS should add a teaching adjustment to the
OPPS.
Response: Unlike payment under the IPPS, the law does not provide
for payment for indirect medical education costs to be made through the
OPPS. Section 1833(t)(2)(E) of the Act, as added by section 4523 of the
BBA, states that the Secretary shall establish, in a budget neutral
manner `` * * * other adjustments as determined to be necessary to
ensure equitable payments, such as adjustments for certain classes of
hospitals.'' We have not found such an adjustment to be necessary to
ensure equitable payments to teaching hospitals and, therefore, have
not developed such an adjustment. 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. Furthermore, in this final rule with comment period, we have
developed payment weights that we believe provide appropriate and
adequate payment for the complex medical services, such as visits
requiring prolonged observation, new technology services and device-
dependent procedures, which we understand are furnished largely by
teaching hospitals. Teaching hospitals benefit from the recalibration
of the APCs and the changes to packaging that are implemented in this
final rule with comment period. The final CY 2008 impacts by class of
hospital are displayed in Table 61 in section XXIV.B. of this final
rule with comment period. Therefore, we do not believe that there is
sufficient reason to develop an adjustment to the OPPS payment to
teaching hospitals for the CY 2008 OPPS.
Comment: The MedPAC commented that while CMS proposed to apply a
multiple procedure reduction to imaging services for CY 2006, CMS did
not adopt this proposal as final but stated that it would continue to
study whether such a reduction was appropriate. The MedPAC asked that
CMS continue to examine ways to improve payment accuracy for imaging
services, including considering applying a multiple procedure reduction
to these services.
Response: The question of whether it would be appropriate to apply
a multiple procedure reduction pertains only to those imaging services
for which we make separate payment. It is not an issue for packaged
imaging services, including the numerous imaging services that we are
packaging for CY 2008 as part of our expanded payment bundles under the
OPPS. The concern, therefore, is partially mitigated by our final CY
2008 packaging policies. Commenters responding to the CY 2006 proposal
OPPS indicated that, in contrast to the MPFS payment rates, the
hospital cost data used by CMS to set payment rates for imaging
services already reflects savings due to the efficiencies of performing
multiple procedures during the same session and that the proposal to
discount second and subsequent procedures would be tantamount to
discounting those procedures twice (70 FR 68707). As we indicated in
our response to that comment, we were unable to disprove commenters'
contentions that there are already efficiencies included in hospitals'
costs and, therefore, in their CCRs and in the median costs on which
the OPPS payments are based (70 FR 68708). However, we believe it is
possible that there may be a relationship between the extent to which
efficiencies are incorporated into the median costs and the degree to
which charge compression affects the median costs for imaging services.
RTI's study of charge compression using inpatient charges found that
use of regression adjusted CCRs would reduce the costs of magnetic
resonance imaging and computed tomography services. This is one of the
categories of hospital services that has high outpatient utilization.
Over the coming year, as discussed earlier in this section of this
final rule with comment period, we will explore through the RTI
contract the results of including hospital outpatient charges to
determine regression-adjusted CCRs for calculation of the median costs
for imaging services. We believe that this information could be useful
in the reassessment of whether it would be appropriate to apply a
multiple procedure reduction to separately paid imaging services.
A detailed discussion of the development of median costs for blood
and blood products is included in section X. of this final rule with
comment period. A discussion of the calculation of medians for APCs
that require one or more implantable devices when the service is
performed is provided in section IV.A. of this final rule with comment
period. The methodology for developing the median costs for composite
APCs is included below in section II.A.4.d. of this final rule with
comment period. A description of the methodology for calculating the
median cost for partial hospitalization services is presented below in
section II.B. of this final rule with comment period.
After consideration of the public comments received, we are
finalizing our proposed CY 2008 methodology for calculating the median
costs upon which the CY 2008 OPPS payment rates are based, with the
modifications described earlier regarding the treatment of services
which are assigned status indicator ``Q.''
Table 2.--CY 2008 Packaged Revenue Codes
------------------------------------------------------------------------
Revenue code Description
------------------------------------------------------------------------
0250.............................. PHARMACY.
0251.............................. GENERIC.
0252.............................. NONGENERIC.
0254.............................. PHARMACY INCIDENT TO OTHER
DIAGNOSTIC.
0255.............................. PHARMACY INCIDENT TO RADIOLOGY.
0257.............................. NONPRESCRIPTION DRUGS.
0258.............................. IV SOLUTIONS.
0259.............................. OTHER PHARMACY.
0260.............................. IV THERAPY, GENERAL CLASS.
0262.............................. IV THERAPY/PHARMACY SERVICES.
0263.............................. SUPPLY/DELIVERY.
[[Page 66609]]
0264.............................. IV THERAPY/SUPPLIES.
0269.............................. OTHER IV THERAPY.
0270.............................. M&S SUPPLIES.
0271.............................. NONSTERILE SUPPLIES.
0272.............................. STERILE SUPPLIES.
0273.............................. TAKE HOME SUPPLIES.
0275.............................. PACEMAKER DRUG.
0276.............................. INTRAOCULAR LENS SOURCE DRUG.
0278.............................. OTHER IMPLANTS.
0279.............................. OTHER M&S SUPPLIES.
0280.............................. ONCOLOGY.
0289.............................. OTHER ONCOLOGY.
0343.............................. DIAGNOSTIC RADIOPHARMS.
0344.............................. THERAPEUTIC RADIOPHARMS.
0370.............................. ANESTHESIA.
0371.............................. ANESTHESIA INCIDENT TO RADIOLOGY.
0372.............................. ANESTHESIA INCIDENT TO OTHER
DIAGNOSTIC.
0379.............................. OTHER ANESTHESIA.
0390.............................. BLOOD STORAGE AND PROCESSING.
0399.............................. OTHER BLOOD STORAGE AND PROCESSING.
0560.............................. MEDICAL SOCIAL SERVICES.
0569.............................. OTHER MEDICAL SOCIAL SERVICES.
0621.............................. SUPPLIES INCIDENT TO RADIOLOGY.
0622.............................. SUPPLIES INCIDENT TO OTHER
DIAGNOSTIC.
0624.............................. INVESTIGATIONAL DEVICE (IDE).
0630.............................. DRUGS REQUIRING SPECIFIC
IDENTIFICATION, GENERAL CLASS.
0631.............................. SINGLE SOURCE.
0632.............................. MULTIPLE.
0633.............................. RESTRICTIVE PRESCRIPTION.
0681.............................. TRAUMA RESPONSE, LEVEL I.
0682.............................. TRAUMA RESPONSE, LEVEL II.
0683.............................. TRAUMA RESPONSE, LEVEL III.
0684.............................. TRAUMA RESPONSE, LEVEL IV.
0689.............................. TRAUMA RESPONSE, OTHER.
0700.............................. CAST ROOM.
0709.............................. OTHER CAST ROOM.
0710.............................. RECOVERY ROOM.
0719.............................. OTHER RECOVERY ROOM.
0720.............................. LABOR ROOM.
0721.............................. LABOR.
0732.............................. TELEMETRY.
0762.............................. OBSERVATION ROOM.
0801.............................. HEMODIALYSIS.
0802.............................. PERITONEAL DIALYSIS.
0803.............................. CAPD.
0804.............................. CCPD.
0809.............................. OTHER INPATIENT DIALYSIS.
0810.............................. ORGAN ACQUISITION.
0819.............................. OTHER ORGAN ACQUISITION.
0821.............................. HEMODIALYSIS COMP OR OTHER RATE.
0824.............................. MAINTENANCE 100%.
0825.............................. SUPPORT SERVICES.
0829.............................. OTHER HEMO OUTPATIENT.
0942.............................. EDUCATION/TRAINING.
------------------------------------------------------------------------
3. Calculation of OPPS Scaled Payment Weights
Using the median APC costs discussed previously, we calculated the
final relative payment weights for each APC for CY 2008 shown in
Addenda A and B to this final rule with comment period. In years prior
to CY 2007, we standardized all the relative payment weights to APC
0601 (Mid Level Clinic Visit) because it was 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.
Beginning with the CY 2007 OPPS, we standardized 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 base because APC 0606 was the middle level clinic
visit APC (that is, Level 3 of five levels). We had 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 were among the most frequently performed services in the
hospital outpatient setting. As proposed for CY 2008, to maintain
consistency in using a median for calculating unscaled weights
representing the median cost of some of the most frequently provided
services, we continued to use the
[[Page 66610]]
median cost of the mid-level clinic APC, proposed APC 0606, to
calculate unscaled weights. Following our standard methodology, but
using the CY 2008 median for APC 0606, for CY 2008 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 2008 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 2007 relative weights to aggregate payments using
the CY 2008 final relative weights. This year, we included payments to
CMHCs in our comparison. Based on this comparison, we adjusted the
relative weights for purposes of budget neutrality. The final unscaled
relative payment weights were adjusted by a weight scaler of 1.3226 for
budget neutrality. In addition to adjusting for increases and decreases
in weight due to the recalibration of APC medians, the scaler also
accounts for any change in the base, other than changes in volume which
are not a factor in the weight scaler. The decline in the weight scaler
compared to the proposed weight scaler of 1.3665 results largely from
the refinement for this final rule with comment period of the proposed
packaging policy to package imaging supervision and interpretation
services only if they are reported on the same date of service as a
HCPCS code that has a status indicator of ``T.'' This change both
increased the median costs for these imaging supervision and
interpretation services and added a significant number of units for
these services that would be separately paid under the final CY 2008
policy. The other factors that contributed to the decline of the scaler
from the proposed rule to this final rule with comment period include
the creation of the observation composite APCs and the increase in the
final CY 2008 payment rate for partial hospitalization services
compared to the proposed payment rate.
The final relative payment weights listed in Addenda A and B to
this final rule with comment period incorporate the recalibration
adjustments discussed in sections II.A.1. and 2. of this final rule
with comment period.
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 final rule with comment period) is included in the budget
neutrality calculations for the CY 2008 OPPS. We did not receive any
public comments on the methodology for calculating scaled weights from
the median costs for the CY 2008 OPPS. Therefore, we are finalizing our
proposed methodology, without modification, including updating of the
budget neutrality scaler for the final rule as proposed.
4. Changes to Packaged Services
a. Background
When the Medicare program was first implemented, it paid for
hospital services (inpatient and outpatient) based on hospital-specific
reasonable costs attributable to furnishing services to Medicare
beneficiaries. Later, the law was amended to limit payment to the
lesser of the hospital's reasonable cost or customary charges for
services furnished to Medicare beneficiaries. Specific service-based
methodologies were then developed for certain types of services, such
as clinical laboratory tests and durable medical equipment, while
payments for outpatient surgical procedures and other diagnostic tests
were based on a blend of the hospital's aggregate Medicare costs for
these services and Medicare's payment for similar services in other
ambulatory settings. While this mix of different payment methodologies
was in use, hospital outpatient services were growing rapidly following
the implementation of the IPPS in 1983. The brisk increase in hospital
outpatient services led to an interest in creating payment incentives
to promote more efficient delivery of hospital outpatient services
through a Medicare prospective payment system for hospital outpatient
services, and the final statutory requirements for the OPPS were
established by the BBA and the BBRA. During the period of time when
different approaches to prospective payment for hospital outpatient
services were being considered, a variety of reports to Congress (June
1988, September 1990, and March 1995) discussed three major issues
related to defining the unit of payment for the payment system,
specifically the extent to which clinically similar procedures should
be grouped for payment purposes and the logic that should be used for
the groupings; the extent to which payment for minor, ancillary
services associated with a significant procedure should be packaged
into a single payment for the procedure (which we refer to as
``packaging''); and the extent to which payment for multiple
significant procedures or multiple units of the same procedure related
to an outpatient encounter or to an episode of care should be bundled
into a single unit of payment (which we refer to as ``bundling''). Both
packaging and bundling were presented as approaches to creating
incentives for efficiency, with their potential policy disadvantages
including inconsistency with other ambulatory fee schedules, reduced
transparency of service-specific payment, and the potential for
hospitals shifting the delivery of packaged or bundled services to
delivery settings other than the hospital outpatient department (HOPD).
The OPPS, like other prospective payment systems, relies on the
concept of averaging, where the payment may be more or less than the
estimated costs of providing a service or package of services for a
particular patient, but with the exception of outlier cases, it is
adequate to ensure access to appropriate care. Decisions about
packaging and bundling payment involve a balance between ensuring some
separate payment for individual services and establishing incentives
for efficiency through larger units of payment. In many situations, the
final payment rate for a package of services may do a better job of
balancing variability in the relative costs of component services
compared to individual rates covering a smaller unit of service without
packaging or bundling. Packaging payments into larger payment bundles
promotes the stability of payment for services over time, a
characteristic that reportedly is very important to hospitals. Unlike
packaged services, the costs of individual services typically show
greater variation because the higher variability for some component
items and services cannot be balanced with lower variability for others
and because relative weights are typically estimated using a smaller
set of claims.
[[Page 66611]]
When compared to service-specific payment, packaging or bundling
payment for component services may change payment at the hospital level
to the extent that there are systematic differences across hospitals in
their performance of the services included in that unit of payment.
Hospitals spending more per case than payment received would be
encouraged to review their service patterns to ensure that they furnish
services as efficiently as possible. Similarly, we believe that
unpackaging services heightens the hospital's focus on pricing
individual services, rather than the efficient delivery of those
services. Over the past several years of the OPPS, greater unpackaging
of payment has occurred simultaneously with continued tremendous growth
in OPPS expenditures as a result of increasing volumes of individual
services, as discussed in further detail below. Also discussed in
further detail below, most recently in its comments to the CY 2007
OPPS/ASC proposed rule and in the context of this rapid spending
growth, MedPAC encouraged CMS to broaden the payment bundles under the
OPPS to encourage providers to use resources efficiently.
As permitted under section 1833(t)(2)(B) of the Act, the OPPS
establishes groups of covered HOPD services, namely APC groups, and
uses them as the basic unit of payment. During the evolution of the
OPPS over the past 7 years, significant attention has been concentrated
on service-specific payment for services furnished to particular
patients, rather than on creating incentives for the efficient delivery
of services through encounter or episode-of-care-based payment. Overall
packaging included in the clinical APCs has decreased, and the
procedure groupings have become smaller as the focus has shifted to
refining service-level payment. Specifically, in the CY 2003 OPPS,
there were 569 APCs, but by CY 2007, the number of APCs had grown to
862, a 51 percent increase in 4 years. Similarly, the percentage of CPT
codes for procedural services that receive packaged payment declined by
over 10 percent between CY 2003 and CY 2007.
Currently, the APC groups reflect a modest degree of packaging,
including packaged payment for minor ancillary services, inexpensive
drugs, medical supplies, implantable devices, capital-related costs,
operating and recovery room use, and anesthesia services. Bundling
payment for multiple significant services provided in the same hospital
outpatient encounter or during an episode of care is not currently a
common OPPS payment practice, because the APC groups generally reflect
only the modest packaging associated with individual procedures or
services. Unconditionally packaged services with HCPCS codes are
identified by the status indicator ``N.'' Conditionally packaged
services, specifically those services whose payment is packaged unless
specific criteria for separate payment are met, are assigned status
indicator ``Q.'' To the extent possible, hospitals may use HCPCS codes
to report any packaged services that were performed, consistent with
CPT or CMS coding guidelines, but packaged costs also may be uncoded
and included in specific revenue code charges. Hospitals include
charges for packaged services on their claims, and the costs associated
with those packaged services are then added into the costs of
separately payable procedures on the same claims in establishing
payment rates for the separately payable services.
Packaging and bundling payment for multiple interrelated services
into a single payment create incentives for providers to furnish
services in the most efficient way by enabling hospitals to manage
their resources with maximum flexibility, thereby encouraging long-term
cost containment. For example, where there are a variety of supplies
that could be used to furnish a service, some of which are more
expensive than others, packaging encourages hospitals to use the least
expensive item that meets the patient's needs, rather than to routinely
use a more expensive item. Packaging also encourages hospitals to
negotiate carefully with manufacturers and suppliers to reduce the
costs of purchased items and services or to explore alternative group
purchasing arrangements, thereby encouraging the most economical health
care. Similarly, packaging encourages hospitals to establish protocols
that ensure that services are furnished only when they are important
and to carefully scrutinize the services ordered by practitioners to
maximize the efficient use of hospital resources. Finally, packaging
payments into larger payment bundles promotes the stability of payment
for services over time. Packaging and bundling also may reduce the
importance of refining service-specific payment because there is more
opportunity for hospitals to average payment across higher cost cases
requiring many ancillary services and lower cost cases requiring fewer
ancillary services.
b. Addressing Growth in OPPS Volume and Spending
Creating additional incentives for providing only necessary
services in the most efficient manner is of vital importance to
Medicare today, in view of the recent explosion of growth in program
expenditures for hospital outpatient services paid under the OPPS. As
illustrated in Table 3 below, total spending has been growing at a rate
of roughly 10 percent per year under the OPPS, and the Medicare
Trustees project that total spending under the OPPS will increase by
more than $3 billion from CY 2007 through CY 2008 to nearly $35
billion. Implementation of the OPPS has not slowed outpatient spending
growth over the past few years; in fact, double-digit spending growth
has generally been occurring. We are greatly concerned with this rate
of increase in program expenditures under the OPPS.
Table 3.-Growth in Expenditures Under Opps From CY 2001-CY 2008
[Projected expenditures for CY 2006-CY 2008 in billions]
--------------------------------------------------------------------------------------------------------------------------------------------------------
OPPS growth CY 2001 CY 2002 CY 2003 CY 2004 CY 2005 CY 2006 CY 2007 CY 2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
Incurred Cost........................................... 17.702 19.561 21.156 23.866 26.572 29.741 32.714 36.072
Percent Increase........................................ .......... 10.5 8.2 12.8 11.3 11.9 10.1 10.26
--------------------------------------------------------------------------------------------------------------------------------------------------------
Based on the Midsession Review of the President's FY 2008 Budget.
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 major reason for the current rates of
growth in the OPPS, rather than general price or enrollment changes.
Table 4 below illustrates the increases in the volume and intensity of
hospital outpatient services over the past several years.
[[Page 66612]]
Table 4.-Percentage Increase in Volume and Intensity of Hospital Outpatient Services
--------------------------------------------------------------------------------------------------------------------------------------------------------
CY 2006 CY 2007 CY 2008
CY 2002 CY 2003 CY 2004 CY 2005 (Est.) (Est.) (Est.)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Percent Increase............................................. 3.5 2.5 7.6 7.4 10.1 9.4 5.8
--------------------------------------------------------------------------------------------------------------------------------------------------------
Based on the Midsession Review of the President's FY 2008 Budget.
For hospital outpatient services, the volume and intensity of
services are estimated to have continued to increase significantly in
recent years, at a rate of 10.1 percent between CY 2005 and CY 2006,
the last two completed calendar years. As we discussed in the CY 2007
OPPS/ASC final rule with comment period (71 FR 68189 through 68190),
the rapid growth in utilization of services under the OPPS shows that
Medicare is paying mainly for more services each year, regardless of
their quality or impact on beneficiary health. In its March 2007 Report
to Congress (pages 55 and 56), MedPAC confirmed that much of the growth
in service volume from 2003 to 2005 resulted from increases in the
number of services per beneficiary who received care, rather than from
increases in the number of beneficiaries served. MedPAC found that
while the rate of growth in service volume declined over that time
period, the complexity of services, defined as the sum of the relative
payment weights of all OPPS services divided by the volume of all
services, increased, and that most of the growth was attributable to
the insertion of devices and the provision of complex imaging services.
MedPAC further found that regression analysis suggested that relatively
complex hospital outpatient services may be more profitable for
hospitals than less complex services. In addition, its analysis
indicated that favorable payments for complex services give hospitals
an incentive to provide more of those complex services rather than
fewer basic services, which increases overall service complexity.
MedPAC expressed concern about this relationship and concluded that the
historically large increases in outpatient volume and service
complexity suggest a need to recalibrate the OPPS. In the future,
MedPAC plans to examine options for recalibrating the payment system to
accurately match payments to the costs of individual services (Medicare
Payment Advisory Commission Report to the Congress: Medicare Payment
Policy, March 2007, pages 55 and 56).
As proposed for the CY 2007 OPPS and finalized for the CY 2009
OPPS, we developed a plan to promote higher quality services under the
OPPS, so that Medicare spending would be directed toward those higher
quality services (71 FR 68189 through 68197). We believe that Medicare
payments should encourage physicians and other providers in their
efforts to achieve better health outcomes for Medicare beneficiaries at
a lower cost. In the CY 2007 OPPS/ASC final rule with comment period,
we discussed the concept of ``value-based purchasing'' in the OPPS as
well as in other Medicare payment systems. ``Value-based purchasing''
may use a range of budget-neutral 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 for Medicare, we
have been working closely with stakeholder partners.
We continue to believe that the collection and submission of
performance data and the public reporting of comparative information
are strong incentives for hospital accountability in general and
quality improvement in particular, while encouraging the most efficient
and effective care. 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 health care delivery. Hospital performance
measures may also provide a foundation for performance-based rather
than volume-based payments.
In the CY 2007 OPPS/ASC final rule with comment period, as a first
step in the OPPS toward value-based purchasing, we finalized a policy
that would employ our equitable adjustment authority under section
1833(t)(2)(E) of the Act to establish an OPPS Reporting Hospital
Quality Data for Annual Payment Update (RHQDAPU) program based on
measures specifically developed to characterize the quality of
outpatient care (71 FR 68197). We finalized implementation of the
program for CY 2009, when we would 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 program. We described the CY
2009 program, which would be based upon CY 2008 hospital reporting of
appropriate 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 reiterated
our belief that ensuring that Medicare beneficiaries receive the care
they need and that such services are of high quality are the necessary
initial steps to incorporating value-based purchasing into the OPPS. We
explained that we are specifically seeking to encourage care that is
both efficient and of high quality in the HOPD.
Subsequent to the publication of the CY 2007 OPPS/ASC final rule
with comment period, section 109(a) of the MIEA-TRHCA, which added
section 1833(t)(19) to the Act, specifies that in the case of a
subsection (d) hospital (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) that does not submit to the Secretary the quality
reporting data required for CY 2009 and each subsequent year, the OPPS
annual update factor shall be reduced by 2.0 percentage points. The
quality reporting program proposed for CY 2008 according to this
provision is referred to as the Hospital Outpatient Quality Data
Reporting Program (HOP QDRP) and is discussed in detail in section
XVII. of this final rule with comment period.
As the next step in our movement toward value-based purchasing
under the OPPS and to complement the HOP QDRP for CY 2009, with measure
reporting beginning in CY 2008, we believe it is important to initiate
specific payment approaches to explicitly encourage efficiency in the
hospital outpatient setting that we believe will control future growth
in the volume of OPPS services. While the HOP QDRP will encourage the
provision of higher quality hospital outpatient services that lead to
improved health outcomes for Medicare beneficiaries, we believe that
more targeted approaches are also necessary to encourage increased
[[Page 66613]]
hospital efficiency. Two alternatives we have considered that would be
feasible under current law include establishing a methodology to
measure the growth in volume and reduce OPPS payment rates to account
for unnecessary increases in volume or developing payment incentives
for hospitals to ensure that they provide necessary services as
efficiently as possible.
With respect to the first alternative, section 1833(t)(2)(F) of the
Act requires us to establish a methodology for controlling unnecessary
increases in the volume of covered OPPS services, and section
1833(t)(9)(C) of the Act authorizes us to adjust the update to the
conversion factor if, under section 1833(t)(2)(F) of the Act, we
determine that there is growth in volume that exceeds established
tolerances. As we indicated in the September 8, 1998 proposed rule
proposing the establishment of the OPPS (63 FR 47585), we considered
creating a system that mirrors the sustainable growth rate (SGR)
methodology applied to the MPFS update to control unnecessary growth in
service volume. However, implementing such a system could have the
potentially undesirable effect of escalating service volume as payment
rates stagnate and hospital costs rise, thus actually resulting in a
growth in volume rather than providing an incentive to control volume.
Therefore, this approach to addressing the volume growth under the OPPS
could inadvertently result in the exact opposite of our desired
outcome.
The second alternative we considered is to expand the packaging of
supportive ancillary services and ultimately bundle payment for
multiple independent services into a single OPPS payment. We believe
that this would create incentives for hospitals to monitor and adjust
the volume and efficiency of services themselves, by enabling them to
manage their resources with maximum flexibility. Instead of external
controls on volume, we believe that it is preferable for the OPPS to
create payment incentives for hospitals to carefully scrutinize their
service patterns to ensure that they furnish only those services that
are necessary for high quality care and to ensure that they provide
care as efficiently as possible. Specifically, we believe that
increased packaging and bundling are the most appropriate payment
strategies to establish such incentives in a prospective payment
system, and that this approach is clearly preferable to the
establishment of an SGR or other methodology that seeks to control
spending by addressing significant growth in volume and program
spending with lower payments.
In its October 6, 2006 letter of comment on the CY 2007 OPPS/ASC
proposed rule, MedPAC urged us to establish broader payment bundles in
both the revised ASC payment system and the OPPS to promote efficient
resource use and better align the two payment systems. In particular,
our proposal for the CY 2008 revised ASC payment system proposed to
package payment for all items and services directly related to the
provision of covered surgical procedures into the ASC facility payment
for the associated surgical procedure (71 FR 49468). These other items
and services included all drugs, biologicals, contrast agents,
implantable devices, and diagnostic services such as imaging. Because a
number of these items and services are separately paid under the OPPS
and the proposal included the establishment of most ASC payment weights
based on the procedures' corresponding OPPS payment weights, MedPAC
encouraged us to align the payment bundles in the two payment systems
by increasing the size of the payment bundles under the OPPS.
Moreover, MedPAC staff indicated in testimony at the January 9,
2007 MedPAC public meeting that the growth in OPPS spending and volume
raises questions about whether the OPPS should be changed to encourage
greater efficiency (page 390 of the January 9, 2007 MedPAC meeting
transcript available at the Web site at: http://www.medpac.gov). MedPAC
staff explained at that time that MedPAC intends to perform a long term
assessment of the design of the OPPS, including considering the
bundling of payments for procedures and visits furnished over a period
of time into a single payment, assessing whether there should be an
expenditure target for hospital outpatient services, evaluating whether
payments for multiple imaging services provided in the same session
should be discounted, and reviewing the methodology used by CMS to
determine relative payment weights for hospital outpatient services. We
welcome MedPAC's study of these areas, particularly with regard to how
we might develop appropriate payment rates for larger bundles of
services.
Because we believe it is important that the OPPS create enhanced
incentives for hospitals to provide only necessary, high quality care
and to provide that care as efficiently as possible, we have given
considerable thought to how we could increase packaging under the OPPS
in a manner that would not place hospitals at substantial financial
risk but which would create incentives for efficiency and volume
control, while providing hospitals with flexibility to provide care in
the most appropriate way for each Medicare beneficiary. We are
considering the possibility of greater bundling of payment for major
hospital outpatient services, which could result in establishing OPPS
payments for episodes of care, and for this reason we particularly
welcome MedPAC's exploration of how such an approach might be
incorporated into the OPPS payment methodology. We are particularly
concerned about the potential for shifting higher cost bundled services
to other ambulatory settings. We are currently considering the complex
policy issues related to the possible development and implementation of
a bundled payment policy for hospital outpatient services that involves
significant services provided over a period of time which could be paid
through an episode-based payment methodology, but we consider this
possible approach to be a long-term policy objective.
We also are examining how we might possibly establish payments for
same-day care encounters, building upon the current use of APCs for
payment through greater packaging of supportive ancillary services.
This could include conditional packaging of supportive ancillary
services into payment for the procedure that is the reason for the OPPS
encounter (for example, diagnostic tests performed on the day of a
scheduled procedure). Another approach could include creation of
composite APCs for frequently performed combinations of surgical
procedures (for example, one APC payment for multiple cardiac
electrophysiologic procedures performed on the same date). Not only
could these encounter-based payment groups create enhanced incentives
for efficiency, but they may also enable us to utilize for ratesetting
many of the multiple procedure claims that are not now used in our
establishment of OPPS rates for single procedures. (We refer readers to
section II.A.1.b. of this final rule with comment period for a more
detailed discussion of the treatment of multiple procedure claims in
the ratesetting process.) In the CY 2008 OPPS/ASC proposed rule, we
proposed two new composite APCs for CY 2008 payment of combinations of
services in two clinical care areas, as discussed in section II.A.4.d.
of this final rule with comment period. In that section, we summarize
and respond to the public comments we received on this proposal
[[Page 66614]]
as we explore the possibility of moving toward basing OPPS payment on
larger packages and bundles of services provided in a single hospital
outpatient encounter.
We intend to involve the APC Panel in our future exploration of how
we can develop encounter-based and episode-based payment groups, and we
look forward to the findings and recommendations of MedPAC in this
area. This is a significant change in direction for the OPPS, and we
specifically seek the recommendations of all stakeholders with regard
to which ancillary services could be packaged and those combinations of
services provided in a single encounter or over time that could be
bundled together for payment. We are hopeful that expanded packaging
and, ultimately, greater bundling under the OPPS may result in
sufficient moderation of growth in volume and spending that further
controls would not be needed. However, if spending were to continue to
escalate at the current rates, even after we have exhausted our options
for increased packaging and bundling, we are considering multiple
options under our authority to address these issues.
c. Packaging Approach
With the exception of the two composite APCs that we proposed for
CY 2008 and discuss in detail in section II.A.4.d. of this final rule
with comment period, we indicated in the CY 2008 OPPS/ASC proposed rule
that we were not prepared to propose an episode-based or fully
developed encounter-based payment methodology for CY 2008 as our next
step in value-based purchasing for the OPPS. However, in reviewing our
approach to revising payment packages and bundles for the proposed
rule, we examined services currently provided under the OPPS, looking
for categories of ancillary items and services for which we believed
payment could be appropriately packaged into larger payment packages
for the encounter. For this first step in creating larger payment
groups, we examined the HCPCS code definitions (including CPT code
descriptors) to see whether there were categories of codes for which
packaging would be a logical expansion of the longstanding packaging
policy that has been a part of the OPPS since its inception. In
general, we have often packaged the costs of selected HCPCS codes into
payment for services reported with other HCPCS codes where we believed
that one code reported an item or service that was integral to the
provision of care that was reported by another HCPCS code.
As an example of a previous change in the OPPS packaging status for
a HCPCS code that is ancillary and supportive, under the CY 2007 OPPS,
we note that CPT code 93641 (Electrophysiologic evaluation of single or
dual chamber pacing cardioverter defibrillator leads including
defibrillation threshold evaluation (induction of arrhythmia, evaluate
of sensing an pacing for arrhythmia termination) at the time of initial
implantation or replacement; with testing of single chamber or dual
chamber cardioverter defibrillator) went from separate to packaged
payment. This service is only performed during the course of a surgical
procedure for implantation or replacement of implantable cardioverter-
defibrillator (ICD) leads, and these surgical implantation procedures
are currently assigned to APC 0106 (Insertion/Replacement/Repair of
Pacemaker and/or Electrodes) and APC 0108 (Insertion/Replacement/Repair
of Cardioverter-Defibrillator Leads). We considered the
electrophysiologic evaluation service (CPT code 93641) to be an
ancillary supportive service that may be performed only in the same
operative session as a procedure that could otherwise be performed
independently of the electrophysiologic evaluation service. In this
particular case, the APC Panel recommended for CY 2007 that we package
payment for this diagnostic test, and we adopted that recommendation
for the CY 2007 OPPS. Making this payment change in this specific case
resulted in the availability of significantly more claims data and,
therefore, establishment of more valid and representative estimated
median costs for the lead insertion and electrophysiologic evaluation
services furnished in the single hospital encounter.
In the case of much of the care furnished in the HOPD, we believe
that it is appropriate to view a complete service as potentially being
reported by a combination of two or more HCPCS codes, rather than a
single code, and to establish payment policy that supports this view.
Ideally, we would consider a complete HOPD service to be the totality
of care furnished in a hospital outpatient encounter or in an episode
of care. In general, we believe that it is particularly appropriate to
package payment for those items and services that are typically
ancillary and supportive into the payment for the primary diagnostic or
therapeutic modalities in which they are used. As a significant first
step towards creating payment units that represent larger units of
service, in development of the proposed rule, we examined whether there
were categories of HCPCS codes that are typically ancillary and
supportive to diagnostic and therapeutic modalities.
Specifically, as our initial substantial step toward creating
larger payment groups for hospital outpatient care, in the CY 2008
OPPS/ASC proposed rule (72 FR 42652), we proposed to package payment
for items and services in the seven categories listed below into the
payment for the primary diagnostic or therapeutic modality to which we
believe these items and services are typically ancillary and
supportive. We specifically chose these categories of HCPCS codes for
packaging because we believe that the items and services described by
the codes in these categories are the HCPCS codes that are typically
ancillary and supportive to a primary diagnostic or therapeutic
modality and, in those cases, are an integral part of the primary
service they support. We proposed to assign status indicator ``N'' to
those HCPCS codes that we believe are always integral to the
performance of the primary modality and to package their costs into the
costs of the separately paid primary services with which they are
billed. We proposed to assign status indicator ``Q'' to those HCPCS
codes that we believe are typically integral to the performance of the
primary modality and to package payment for their costs into the costs
of the separately paid primary services with which they are usually
billed but to pay them separately in those uncommon cases in which no
other separately paid primary service is furnished in the hospital
outpatient encounter.
For ease of reference in our subsequent discussion in each of the
seven areas, we refer to the HCPCS codes for which we proposed to
package (or conditionally package) payment as dependent services. We
use the term ``independent service'' to refer to the HCPCS codes that
represent the primary therapeutic or diagnostic modality into which we
are proposing to package payment for the dependent service. We note
that, in future years as we consider the development of larger payment
groups that more broadly reflect services provided in an encounter or
episode of care, it is possible that we might propose to bundle payment
for a service that we now refer to as ``independent'' in this final
rule with comment period.
Specifically, we proposed to package the payment for HCPCS codes
describing the dependent items and services in the following seven
categories into the payment for the
[[Page 66615]]
independent services with which they are furnished:
Guidance services
Image processing services
Intraoperative services
Imaging supervision and interpretation services
Diagnostic radiopharmaceuticals
Contrast media
Observation services
In the proposed rule, we identified the HCPCS codes we proposed to
package for CY 2008, explained our rationale for proposing to package
the codes in these categories, provided examples of how HCPCS and APC
median costs and payments would change under these proposals, and
discussed the impact of these changes under each category, as follows:
The median costs of services at the HCPCS level for many separately
paid procedures changed as a result of our proposal because we proposed
to change the composition of the payment packages associated with the
HCPCS codes. Moreover, as a result of changes to the HCPCS median
costs, we proposed to reassign some HCPCS codes to different clinical
APCs for CY 2008 to avoid 2 times violations and to ensure continuing
clinical and resource homogeneity of the APCs. Therefore, the proposed
APC median costs changed not only as a result of the increased
packaging itself but also as a result of the migration of HCPCS codes
into and out of APCs through APC reconfiguration. The file of HCPCS
code and APC median costs resulting from our proposal is found under
supporting documentation for the proposed rule on the CMS Web site at
http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage.
Review of the HCPCS median costs for the proposed rule indicated
that, while the proposed median costs rise for some HCPCS codes as a
result of increased packaging that expands the costs included in the
payment packages, there are also cases in which the proposed median
costs decline as a result of these proposed changes. While it seems
intuitive to believe that the proposed median costs of the remaining
separately paid services should rise when the costs of services
previously paid separately are packaged into larger payment groups, it
is more challenging to understand why the proposed median costs of
separately paid services would not change or would decline when the
costs of previously paid services are packaged.
Medians are generally more stable than means because they are less
sensitive to extreme observations, but medians typically do not reflect
subtle changes in cost distributions. The OPPS' use of medians rather
than means usually results in relative weight estimates being less
sensitive to packaging decisions. Specifically, the median cost for a
particular independent procedure generally will be higher as a result
of added packaging, but also could change little or be lower because
median costs typically do not reflect small distributional changes and
also because changes to the packaged HCPCS codes affect both the number
and composition of single bills and the mix of hospitals contributing
those single bills. Such a decline, no change, or an increase in the
median cost at the HCPCS code level could result from a change in the
number of single bills used to set the median cost. With greater
packaging, more ``natural'' single bills are created for some codes but
fewer ``pseudo'' single bills are created. Thus, some APCs gain single
bills and some lose single bills due to packaging changes, as well as
to the reassignment of some codes to different APCs. When more claims
from a different mix of providers are used to set the median cost for
the HCPCS code, the median cost could move higher or lower within the
array of per claim costs.
Similarly, revisions to APC assignments that are necessary to
resolve 2 times violations that could arise as a result of changes in
the HCPCS median cost for one or more codes due to additional packaging
may also result in increases or decreases to APC median costs and,
therefore, to increases or decreases in the payments for HCPCS codes
that would not be otherwise affected except for the CY 2008 proposed
packaging approach for the seven categories of items and services.
We examined the aggregate impact of making these proposed changes
on payment for CY 2008 in the proposed rule. Because the OPPS is a
budget neutral payment system in which the amount of payment weight in
the system is annually adjusted for changes in expenditures created by
changes in APC weights and codes (but is not currently adjusted based
on estimated growth in service volume), the effects of the packaging
changes we proposed resulted in changes to scaled weights and,
therefore, to the proposed payment rates for all separately paid
procedures. These changes resulted from both shifts in median costs as
a result of increased packaging, changes in multiple procedure
discounting patterns, and a higher weight scaler that was applied to
all unscaled APC weights. (We refer readers to section II.A.3. of this
final rule with comment period for an explanation of the weight
scaler.) In a budget neutral system, the monies previously paid for
services that were proposed to be packaged are not lost, but are
redistributed to all other services. A higher weight scaler would
increase payment rates relative to observed median costs for
independent services by redistributing the lost weight of packaged
items that historically have been paid separately and the lost weight
when the median costs of independent services did not completely
reflect the full incremental cost of the packaged services. The impact
of the cumulative changes for the CY 2008 OPPS payments is discussed in
section XXIV.B. of this final rule with comment period.
We estimated that our CY 2008 packaging proposal would redistribute
approximately 1.2 percent of the estimated CY 2007 base year
expenditures under the OPPS. The monies associated with this
redistribution were in addition to any increases that would otherwise
occur due to a higher median cost for the APC as a result of the
expanded payment package. If the relative weight for a particular APC
decreased as a result of the proposed packaging approach, the increased
weight scaler may or may not result in a relative weight that is equal
to or greater than the relative weight that would occur without the
proposed packaging approach. In general, the packaging that we proposed
would have more effect on payment for some services than on payment for
others because the dependent items and services that we proposed for
packaging are furnished more often with some independent services than
with others. However, because of the amount of payment weight that
would be redistributed by our proposal, there would be some impact on
payments for all OPPS services whose rates are set based on payment
weights, and the impact on any given hospital would vary based on the
mix of services furnished by the hospital.
We received many, often widely diverging, public comments on the CY
2008 proposed packaging approach. In many cases the comments were
generally applicable to the totality of the packaging proposal and, in
other cases, the same general comments were made but only with regard
to a specific category or set of services of interest to the commenter.
We have addressed all similar public comments in the discussion of
general comments, whether they were made in general or for specific
categories of services, because the same response applies
[[Page 66616]]
whether the comment was on packaging in general or on a specific
service. We have limited the summary of public comments and our
responses in the individual category discussions to issues that pertain
only to the category or specific services within the category.
During the September 2007 APC Panel meeting, the APC Panel
supported packaging for contrast agents, image processing services,
guidance (except for radiation oncology guidance procedures),
diagnostic radiopharmaceuticals with a median per day cost of less than
$200, and intraoperative testing other than possibly for CPT code 96020
(Neurofunctional testing selection and administration during
noninvasive imaging functional brain mapping, with test administered
entirely by a physician or psychologist, with review of test results
and report). The Panel recommended a delay in packaging for imaging
supervision and interpretation services because of excessive payment
reductions that the Panel believed would occur under the CMS proposal,
particularly with regard to packaging payment for those supervision and
interpretation services that already include packaged injection
services. The Panel did not support packaging of observation services,
although it suggested that if CMS were to package observation, it
should instead create a composite APC (or a group of composite APCs)
for observation and the related visit services, without restriction to
specific clinical conditions. The APC Panel also recommended that CMS
provide additional information in the CY 2008 final rule with comment
period about packaging, including crosswalks and information clarifying
how newly packaged services map back to primary procedures.
Comment: MedPAC generally supported the proposed packaging because
the services proposed for packaging are typically furnished on the same
day as a separately paid service and there is little potential for them
to be furnished on another date to avoid the effects of packaging.
MedPAC explained that packaging of observation services is logical
because currently 70 percent of observation care is packaged. MedPAC's
principal concern about the proposed packaging of observation was that
this approach could result in hospitals' costs being higher than OPPS
payments in some cases, and thereby create an incentive for inpatient
admissions. It encouraged CMS to carefully monitoring whether hospitals
change their behavior with regard to inpatient admissions.
Some commenters supported encounter-based or episode-based payment,
but asked that this approach be based on single encounter only and not
span a period of time, because they believed that it would be very
difficult to set rates for periods of recurring services. The
commenters supported use of multiple procedure claims and payment for
combinations of services but encouraged CMS to carefully evaluate the
overall impact of packaging on all hospitals. Other commenters
suggested that CMS package only services that are low cost and
furnished at a high frequency with the independent service. Several
commenters stated that CMS should not finalize the proposed packaging
approach because it would lead to inappropriate payment, including both
overpayments and underpayments.
Several commenters asked that CMS delay the packaging approach for
at least a year because they believed the proposed rule did not furnish
sufficient data analysis in support of the proposal. They asserted that
the aggregate impact analysis provided no information that commenters
could use to evaluate the individual codes proposed to be packaged,
making it impossible for the public to determine how payment for
services would be affected. Some commenters requested that CMS furnish
the same level of impact discussion for each of the services in each of
the categories as it did for the composite APCs. Other commenters asked
CMS to identify the percent of charges for dependent services that were
packaged into each independent procedure, identify all independent
procedures into which cost was packaged from each packaged procedure,
and identify the cost of each procedure code with and without the
proposed packaging. They recommended that, before implementing the
proposed packaging, CMS publish all HCPCS and revenue codes and the
costs for each that enter into the consideration of packaging for every
code proposed to be packaged. The commenters believed that the lack of
transparency, together with late availability of a correct OPPS
proposed rule claims data set, made it difficult to determine whether
packaged costs were retained or lost in the median setting process.
Other commenters suggested that CMS explicitly crosswalk packaged
services to identified independent services, rather than packaging
payment into the independent service with which the packaged services
is billed on each claim. They asserted that no service should be
packaged unless it is furnished the majority of the time with the
specified independent service. The commenters stated that items and
services should be packaged only where there are substitutable services
that could be chosen by the hospital, and that no packaging should
occur where there is only one dependent service that would be provided
with the independent service.
Some commenters contended that CMS should not implement the
proposed packaging changes until after it implements an adjustment for
charge compression because errors in the proposed rates as a result of
charge compression would result in too little payment being packaged
into the independent service and would create disincentives for
hospital to furnish the packaged services, thus harming beneficiary
access to advanced technologies.
Some commenters requested that CMS develop and propose a set of
criteria for packaging services that would be open to public comment
and that would control whether and, if so, when CMS could package
payment for a service. The commenters stated that the criteria in the
proposed rule were too vague, undefined, and subjective to identify
which codes should be packaged. The commenters provided criteria that
they believe should govern whether a service should be packaged. The
suggested criteria included, but were not limited to, requiring that
packaging should only be adopted for high volume, low cost, minor and
ancillary services that are very frequently performed with the
specified independent service; no packaging of services that require
specialized equipment or devices; no packaging of services that are
only furnished in a small number of hospitals; no packaging of add-on
services unless the service is furnished with its base code at least 50
percent or 75 percent of the time; packaging only when a service is
being packaged into a specified service and, therefore, no general
packaging of services into the service with which it is performed; no
packaging unless CMS has provided the public with a full data
assessment of the effects of packaging each service; and no packaging
if the median cost for the code exceeds an established amount.
Other commenters suggested CMS not implement the proposed packaging
because the 60-day comment period provided insufficient time for
analysis and because the APC Panel recommendations and report were not
posted on the Web site immediately after the meeting.
Response: We have reviewed all of the public comments we received
on the
[[Page 66617]]
proposed packaging approach, and we have decided to finalize our
proposal with significant modifications and refinements to address some
of the concerns raised by commenters on our proposal to package payment
for diagnostic radiopharmaceuticals, imaging supervision and
interpretation services, contrast agents, and observation services. We
refer readers to sections II.A.4.c.(4), (5), (6), and (7) of this final
rule with comment period for detailed discussion of these modifications
and section II.A.2 of this final rule with comment period for
discussion of the changes we made to the data process in this regard.
We are finalizing our proposal for guidance, image processing, and
intraoperative services without substantial modification. Table 10,
which appears in section II.A.4., contains a comprehensive list of all
codes in the final seven categories for which we will package payment
either unconditionally (to which we assign status indicator ``N'') or
conditionally, providing separate payment if certain criteria are met
(to which we assign status indicator ``Q''). There is a category of
conditionally packaged codes assigned status indicator ``Q,'' which we
previously referred to as ``special'' packaged codes because their
payment was packaged when provided on the same date as a service that
was assigned status indicator ``S,'' ``T,'' ``V,'' or ``X.'' These
``special'' packaged codes will now be referred to as ``STVX-packaged
codes.'' We have identified a new category of conditionally packaged
codes that are called ``T-packaged codes,'' whose payment is packaged
when provided on the same date as another service that is assigned
status indicator ``T.'' The rationale for these changes are discussed
in detail below in section II.A.4.c.(4) of this final rule with comment
period.
We believe that it is appropriate and fully consistent with the
principles of a prospective payment system to package payment for
ancillary and supportive services into the payment for the independent
service with which they are furnished as a means of making payment for
a more comprehensive service package. Although separate payment will no
longer be made for the packaged services, the payments for the
independent services with which they are furnished will reflect the
costs of the packaged services to the extent that the packaged services
are provided with the independent service. We recognize that, in some
cases, certain supportive and ancillary dependent services are
furnished with only one independent service, and in other cases they
are furnished with many independent services. Similarly, in some cases
they are furnished frequently with independent services, and in some
cases they are uncommonly furnished with independent services.
We believe that packaging should reflect the reality of how the
services are furnished and reported on claims by hospitals. We believe
that nonspecific packaging (as opposed to selected code packaging)
based on combinations of services observed on hospital claims is fully
appropriate because of the myriad combinations of services that can be
appropriately provided together. This approach to packaging payment has
long existed in prospective payment systems, including the OPPS. For
example, in the IPPS, Medicare's oldest prospective payment system,
payment for all services furnished is packaged into a single payment
for an entire hospital inpatient stay that is based on the diagnosis-
related group (DRG) into which the stay is categorized. The DRG payment
packages together all payment for routine care, drugs, biologicals,
medical supplies, diagnostic tests, and all other covered services that
were provided to the patient, regardless of the extent to which
different patients in the same DRG received somewhat different services
during their stay. We believe that a similar approach to nonspecific
packaging under the OPPS is likewise fully appropriate. We have used
this packaging approach for ratesetting throughout the history of the
OPPS, and note that payment for APC groups currently reflects
significant nonspecific packaging in many cases. Similarly, we believe
that it is appropriate to establish under the OPPS a single payment for
multiple independent procedures that are frequently furnished together.
For that reason, we are adopting five composite APCs for CY 2008 and
intend to explore developing others.
We do not agree with the commenters that we should not package a
service unless it is a low cost ancillary and supportive service that
appears frequently with an independent service. To establish that
policy would negate the concept of averaging that is an underlying
premise of a prospective payment system by packaging only services that
will increase the payment for the independent service. To do that would
also create incentives for hospitals to provide ancillary and dependent
services that are higher cost or historically were infrequently
furnished with an independent service and would remain separately paid.
Similarly, we do not agree that we should not finalize the proposed
packaging approach because it will ``overpay'' some services and
``underpay'' others. Payment based on a measure of central tendency is
also a principle of any prospective payment system. In some cases,
payment in an individual case exceeds the average cost and in other
cases payment is less than the average cost, but on balance, payment
should approximate the relative cost of the average case, recognizing
that the OPPS, as created in the statute, was not intended to pay the
full cost of HOPD services.
We also do not agree that it would be beneficial to delay the
implementation of the proposed packaging approach for a year because
that would delay the implementation of incentives under the OPPS for
hospitals to look carefully at ways that they could provide care more
efficiently. We recognize that, as with any payment policy, there will
be affected parties that will ask for changes to the policy, and we are
always willing to hear their concerns and to make changes if the
changes are appropriate. Moreover, both APC and status indicator
assignments are open to public comment each year in the proposed rule,
and hence affected parties may provide their arguments for separate
payment as part of that process in the future.
We further disagree that we should delay or not finalize the
proposed packaging approach pending provision of the extensive data
that the commenters requested. We make available a considerable amount
of data for public analysis each year and while we are not developing
and providing the extensively detailed information that the commenters
request, we provide the public use files of claims and a detailed
narrative description of our data process that the public can use to
perform any desired analyses. While we acknowledge that we needed to
issue a second corrected file of claims data, the second file differed
from the first only in that it deleted a relatively small number of
duplicate claims for observation that would have been used to calculate
an APC rate for separately payable observation, had we proposed to pay
separately for observation, and hence we believe that the accidental
inclusion of these duplicate claims for observation care should have
had little or no effect on the majority of studies of the HCPCS codes
we proposed to package.
With regard to the request for extensive data on all HCPCS codes we
proposed to package, it would not be possible for us to anticipate the
specific combinations of services of interest to the public. In
addition, we believe that
[[Page 66618]]
the commenters must examine the data themselves to develop the specific
arguments to support their requests for changes to payments under the
OPPS. We note that we pay hospitals under the OPPS, and we showed the
impact of the CY 2008 packaging proposal on payment to different
classes of hospitals in Table 67 of the proposed rule (72 FR 42822
through 42824). We believe our estimate of the impact of these changes
provided valuable information to the hospitals that would receive
packaged payment for services that had been previously paid separately
under the OPPS.
With regard to the public comments that we should explicitly
crosswalk packaged codes to the independent codes into which the costs
would be packaged, we do not believe that this is feasible, given the
myriad combinations of services that are furnished in the HOPD, nor is
it consistent with the principles of a prospective payment system,
which bases payment on real occurrences of services that are furnished
by hospitals and reported on claims. Moreover, creation of such a
crosswalk would undoubtedly result in omissions of appropriate
packaging of services and would create a maintenance task that would
not be sustainable, given the number of changes to HCPCS codes each
year and the ever changing way in which services are furnished.
Similarly, it is not consistent with the concept of packaging within a
prospective payment system to package only those services for which
there are substitutes that could be furnished. In contrast, it is fully
consistent with the principles of a prospective payment system for
groups of services to package items and services that are always
furnished with an independent service and for which there are no
substitutes.
We also do not agree that we should delay creation of larger
payment bundles through packaging until after there is adjustment for
charge compression under the OPPS. As we discuss in section II.A.1.c.
of this final rule with comment period, we will consider whether to use
regression-adjusted CCRs to adjust for charge compression under the
OPPS after RTI reviews the OPPS cost estimation process, including an
assessment of the revenue code-to-cost center crosswalk and estimating
regression-adjusted CCRs from a model that includes outpatient charges.
There is no reason to delay the creation of incentives for encouraging
cost-effective utilization and efficiency in the provision of HOPD
services until a decision is made regarding the appropriateness of
using regression-adjusted CCRs to estimate OPPS costs.
We do not agree that we should develop and establish criteria with
stakeholder input before we finalize the packaging proposal. Nor do we
believe that the specific criteria the commenters recommended are
appropriate for determining when services should be packaged. The
criteria that the commenters provided are focused almost exclusively on
preventing packaging, rather than on determining when packaging would
be appropriate. We believe that packaging is appropriate when the
nature of a service is such that it is supportive and ancillary to
another service, whether the dependent service is frequently furnished
with the independent service or not and regardless of the cost of the
supportive ancillary service. This is largely a clinical decision based
on the nature of the service being considered for packaging.
Lastly, we do not agree that we should not implement the proposed
changes because the commenters believed that the 60 day comment period
was insufficient or because the APC Panel recommendations and report
were not posted to the Web site immediately after the public meeting.
The 60 day comment period is generally the standard comment period for
the proposed rule process. The availability of updated claims and cost
report data necessary to develop the proposed rule and issue the final
rule for the OPPS precludes a longer period for comment. Moreover, we
do not believe that the Web site posting of the APC Panel
recommendations and report is necessary for the public to provide
meaningful comments, in light of the fact that the APC Panel meeting is
open to the public.
We are not accepting the recommendation of the APC Panel to provide
information in this final rule with comment period clarifying how newly
packaged services map back to primary procedures because we would be
unable to display in a meaningful way all of the many combinations of
services that may be of interest to the public. Moreover, given the
numerous new, refined, and interrelated payment policies finalized for
CY 2008 involving APC reconfiguration, HCPCS migration, reduction in
the numbers of low volume APCs, and others, to adopt the APC Panel's
example of simulating median costs holding all other CY 2008 policies
constant for HCPCS codes with and without the additional packaging of
those services newly packaged for CY 2008 would not provide meaningful
comparative information. Almost certainly, if we were not to adopt
packaging of the additional services for CY 2008, the APC
configurations, bypass list, single claims available for ratesetting,
and other important features upon which the final median costs depend
would differ in significant ways from those aspects under our final CY
2008 policies.
Comment: A number of commenters disagreed with the CMS estimate of
the amount of payment that would be redistributed under the proposed
rule. The commenters indicated that the services proposed to be newly
packaged constitute 6 percent of the OPPS costs, although CMS estimated
that the packaging proposal would redistribute 1.2 percent of the CY
2008 expenditures under the OPPS. They attributed the difference in
cost estimates to the methodology for applying status indicator ``Q.''
The commenters believed that the resulting impact analysis would be
quite different from CMS' estimated impact displayed in the proposed
rule and, therefore, the implications of the policy are not fully
understood. They objected to packaging of observation services in
particular, but recommended that CMS reevaluate the entire packaging
proposal in light of methodological and data concerns.
Response: In the proposed rule, we estimated that the proposed
packaging approach would redistribute 1.2 percent of the CY 2007 base
expenditures under the OPPS to other OPPS services as part of our
budget neutrality adjustments for the proposed CY 2008 payment system.
This 1.2 percent is the aggregate payment weight reduction from the
packaging proposal, where the medians are marginally less than the
costs for the individual services prior to packaging. This is not
inconsistent with a finding that the total cost of services proposed to
be packaged constitutes 6 percent of HOPD costs. These percentages
measure different things. The first provides an estimate of money
redistributed to other services and the second an estimate of the
proportion of OPPS spending on services addressed by the policy. We
understand, and intended, that the packaging proposal affect services
responsible for significant OPPS spending, in order to provide
hospitals with meaningful incentives to examine their patterns of care
delivery and improve efficiency. The 1.2 percent reflects the
difference in total weight with and without the packaging proposal
relative to the CY 2007 total base weight. Whether or not the 1.2
percent of redistributed dollars was entirely attributable to the
proposed policy for estimating the median cost for ``Q'' status
indicator services cannot be
[[Page 66619]]
determined. For this final rule with comment period, we made
modifications to the policy governing the handling of many services
assigned status indicator ``Q,'' as discussed in section II.A.4.c.(4)
of this final rule with comment period, that resulted in use of more
claims data and significant changes to the median costs for some
services. We also accepted the public comments that recommended that we
create a composite APC for observation services, as discussed in
section II.A.4.c.(7) of this final rule with comment period.
Comment: Some commenters stated that CMS must undertake provider
education and claims monitoring because providers will cease to bill
HCPCS codes and charges for packaged services, which will result in
lower payment rates than would otherwise be made if they reported all
codes and charges and thus the costs of packaged services would be lost
to the payment system in future years. They indicated that this
presents huge operational challenges to hospitals to ensure that they
bill and charge for the packaged codes. Other commenters believed that
the implementation of increased packaging will be particularly
difficult in CY 2008 because CMS is simultaneously implementing
Medicare-Severity DRGs (MS-DRGs) for IPPS payment, which also poses
operational challenges for hospitals.
Response: We do not believe that there will be a significant change
in what hospitals charge and report for the services they furnish to
Medicare beneficiaries and to others as a result of the increased
packaging for the CY 2008 OPPS. Medicare cost reporting standards
specify that hospitals must impose the same charges for Medicare
patients as for other patients. We are often told by hospitals that
many private payers pay based on a percentage of charges and that
hospital chargemasters do not differentiate between the charges to
Medicare patients and others. Therefore, we have no reason to believe
that hospitals will cease to report charges and HCPCS codes for
packaged services they provide to Medicare beneficiaries. We expect
that hospitals, as other prudent businesses, will have a quality review
process that ensures that they accurately and completely report the
services they furnish, with the appropriate charges for those services
to Medicare and all other payers. Therefore, we do not see either the
need or the responsibility to undertake a special effort to educate
providers to report and charge Medicare for the services they furnish,
whether separately paid or packaged. According to our longstanding
policy, we will continue to encourage hospitals to report the HCPCS
codes and associated charges for all services they provide, taking into
consideration all CPT, OPPS, and local contracture instructions,
regardless of whether payment for those HCPCS codes is packaged or
separately provided. Similarly, we do not believe that the
implementation of MS-DRGs will create operational issues for hospitals
that would be complicated by increased packaging under the OPPS.
Comment: Some commenters asserted that increased packaging will
create disincentives to provide certain services and that providers may
stop furnishing these services to Medicare beneficiaries. The
commenters stated that increased packaging would reduce expenditures,
but the ultimate result would be reduced access to necessary care as
the payment incentives to provide care are reduced. Other commenters
believed that increased packaging will result in services being
furnished on multiple days in order to maximize payment, which will
increase, rather than decrease, volumes of services and provide a
significant inconvenience to beneficiaries.
Response: We also do not agree that beneficiary access to care will
be harmed by increased packaging. We believe that packaging will create
incentives for hospitals and their physician partners to work together
to establish appropriate protocols that will eliminate unnecessary
services where they exist and will institutionalize approaches to
providing necessary services more efficiently. Where this review
results in reductions in services that are only marginally beneficial,
we believe that this could improve rather than harm the quality of care
for beneficiaries because every service furnished in a hospital carries
some level of risk to the patient. Similarly, where this review results
in the concentration of some services in a reduced number of hospitals
in the community, we believe that the quality of care and hospital
efficiency may both be enhanced as a result. The medical literature
shows that concentration of services in certain hospitals often results
in both greater efficiency and higher quality of care for patients.
Moreover, we do not believe that packaging will result in Medicare
beneficiaries being treated differently from other patients with regard
to the care they receive in the hospital. A hospital may have its
provider agreement terminated by Medicare under 42 CFR 489.53(a)(2) if
it places restrictions on the persons it accepts for treatment and
either fails to exempt Medicare beneficiaries from those restrictions
or apply them to Medicare beneficiaries the same as to all other
persons seeking care. We do not believe that a hospital would risk
termination of its provider agreement by Medicare by refusing to
furnish a medically necessary service to a Medicare beneficiary,
although it provides the same service to other patients for the same
clinical indications.
As we indicated in the proposed rule, we will examine our claims
data for patterns of fragmented care and if we find a pattern in which
a hospital appears to be fragmenting care across multiple days, we will
refer it for investigation to the QIO or to the program safeguard
contractor, as appropriate to the circumstances we find. However, we do
not believe that, in general, hospitals would routinely, and for
purposes of financial gain, require patients to return on multiple days
to receive services that could have been furnished on the same day.
Comment: One commenter objected to the implication in the proposed
rule that hospitals provide whatever services they wish at whatever
cost, with their only concern being payment for the services, and that
payment rates could motivate hospitals to report services on separate
claims or split the service among different hospitals in order to be
paid more. The commenter stated that 42 CFR 411.15(m) requires that
hospitals must furnish and bill for services necessary to complete an
outpatient encounter and that, therefore, it would be a violation of
CMS regulations for a hospital to deliver part of the service at one
hospital and the rest at another hospital.
Response: We believe that hospitals strive to provide the best care
they can to the patients they serve. However, we are aware that there
are financial pressures on hospitals that might motivate some of them
to split services in such a way as to maximize payments. While we do
not expect that hospitals would routinely change the way they furnish
services or the way they bill in order to maximize payment, we do
believe that it would be possible, and hence we offered the cautionary
note in the proposed rule that we will consider that possibility as we
review our claims data. Other commenters, as described in the preceding
comment, stated that volumes of services and expenditures would
increase because hospitals would provide services on multiple days to
maximize payment.
We note that 42 CFR 411.15(m) specifies exclusions from Medicare
coverage in cases in which the hospital does not furnish a service
directly or
[[Page 66620]]
under arrangements as defined in 42 CFR 409.3 and, therefore, would not
prohibit a hospital from discharging a patient and sending that patient
to another hospital for a service that would otherwise be packaged if
furnished during the same encounter. However, as noted above, a
hospital that does not make available the same services to Medicare
beneficiaries as to its other hospital patients can be terminated from
Medicare under 42 CFR 489.53(a)(2). Additionally, we remind hospitals
that any business models or arrangements they make for the provision of
services intended to be billed by that hospital must comply with all
applicable laws and regulations, including, but not limited to, the
Stark law and other anti-kickback laws, the provider-based rules at 42
CFR 413.65, the ``incident-to'' rules at 42 CFR 410.27, and the
conditions for outpatient diagnostic services at 42 CFR 410.28. In
regard to hospital services provided under arrangements, as defined in
42 CFR 409.3, we have specified in the Eligibility and Entitlement
Manual that, ``In permitting providers to furnish services under
arrangements, it was not intended that the provider merely serve as a
billing mechanism for the other party. Accordingly, for services
provided under arrangements to be covered, the provider must exercise
professional responsibility over the arranged for services'' (Pub. 100-
1, Chapter 5, section 10.3). Therefore, we would not expect hospitals
to send patients to a separate entity merely to avoid packaged payment,
but, as stated above, we will consider that possibility as we review
our claims data.
Comment: Some commenters suggested that CMS work with and through
the AMA process in making any packaging decisions and not make any
arbitrary and single-sided bundling decisions that have not been fully
reviewed and analyzed for impact by the stakeholders. They suggested
that CMS discuss with the AMA CPT Editorial Panel the potential for
unintended consequences of proposed packaging or bundling on the
establishment of CPT codes. For example, one commenter believed that
packaging add-on codes, which the commenter viewed as integral to
maintaining flexibility of CPT coding, would likely discourage future
consideration of creating add-on codes as a means to describe code-
specific procedures and resources. Other commenters objected to what
they view as a ``codebook'' approach to determining what should be
packaged. The commenters stated that CMS not rely on CPT and HCPCS code
descriptors because the descriptors are complex and many do not
accurately describe the services furnished. Some commenters argued that
CMS should pay across settings in the same way and, therefore, should
not package under the OPPS services that are paid separately under the
MPFS.
Response: Our general process for developing the OPPS, including
making major payment policy decisions, is prescribed by the
Administrative Procedure Act (APA) and the Federal Advisory Committee
Act (FACA). As such, proposed payment rates and the attendant policies
are open to public comment both through the Federal Register notice and
comment rulemaking process and through the public meetings of the APC
Panel, which is a Federal Advisory Committee chartered by the Secretary
of Health and Human Services. Therefore, our proposed packaging for the
CY 2008 OPPS and the decisions we are announcing in this final rule
with comment period are neither arbitrary nor single-sided, as all
stakeholders have had the opportunity to comment. In this final rule
with comment period, we are responding to their comments. We note that
the AMA, as a member of the public, has the same opportunity to comment
on the packaging proposal in the proposed rule as any other member of
the public.
We believe that it is entirely appropriate to rely on the HCPCS
descriptors, including the AMA's CPT descriptors, for the definition of
the services furnished for purposes of the proposed packaging approach
and other payment policies. The OPPS is based on the definitions of
services reported with HCPCS codes, of which the CPT code set is a
fundamental part. The HCPCS codes are the only means by which hospitals
report the services they furnish and the charges for those services
and, therefore, they are basis of the OPPS. For that reason, we look to
the HCPCS definition of the service to determine whether a particular
service is ancillary and supportive of another service. To the extent
that there are changes to the HCPCS codes and, by extension, to the CPT
code descriptors, we will reevaluate the decisions we make with regard
to packaging payment. However, we do not believe that the AMA's CPT
Editorial Board is influenced by OPPS payment policy in its
deliberations, nor should it be influenced by OPPS payment policy in
its creation of CPT codes.
Moreover, we disagree that we should not package payment for
ancillary and supportive services because the MPFS pays separately for
them. The OPPS is not a fee schedule, but a prospective payment system
based on relative weights derived from costs and charges. Packaging of
payments into appropriate groups is a fundamental principle that
distinguishes a prospective payment system from a fee schedule and we
do not believe that we should refrain from packaging payment for
ancillary and supportive services into payment for the independent
services with which they are furnished because they may be treated
differently in the MPFS or because of the unlikely possibility that
this policy may have some influence on the AMA CPT Editorial Panel's
decisions regarding creation of codes.
Comment: One commenter stated that the concept of creating
incentives for hospitals to negotiate better prices on goods and
services through packaging is not applicable to small rural hospitals
and, therefore, it should not apply to them. The commenter argued that
smaller rural hospitals cannot negotiate for better prices on goods and
services because they buy smaller amounts of products and lack the
ability that large urban hospitals have to negotiate for better prices
on goods and services.
Response: We believe that the creation of incentives for hospitals
to seek more efficient ways of furnishing services is applicable to all
hospitals, including small rural hospitals. Small rural hospitals and
their physician partners have the same capacity and capability as other
hospitals to evaluate the appropriateness and efficiency of the
packaged services they furnish. Moreover, small rural hospitals can
join in cooperatives and group purchasing organizations that can
achieve purchasing efficiencies that they could not achieve by
themselves. We recognize that some costs are higher for certain
categories of rural hospitals, therefore we have provided the 7.1
percent rural adjustment for rural SCHs. Moreover, the law holds
harmless rural hospitals with 100 or fewer beds. However, we also
expect that small rural hospitals will be motivated by the packaging
approach to seek ways of furnishing services as efficiently as possible
and to eliminate services that are essential to the appropriate
treatment of the patient in any clinical case.
Comment: Some commenters contended that the proposed packaging
approach has the potential for systemwide net savings and
redistribution of payments away from hospitals that invested in high-
cost equipment and toward hospitals that do not have such costs. They
believed that charge compression contributes to this
[[Page 66621]]
problem because hospitals are limited in what they can charge, and the
allocation of radiology equipment capital costs exacerbates the
problem. The commenters suggested that CMS not finalize the packaging
proposal because packaging creates incentives for hospitals to divest
themselves of important but expensive technologies because those
technologies have ceased to be profitable.
Response: We agree that there is the potential for systemwide
redistribution of payments away from hospitals that invested in costly
equipment for services for which payment will be packaged and toward
hospitals that do not have such costs. However, to the extent that
packaging payment for ancillary and supportive services reduces the
amount of payment weight in the system for separately paid services,
that amount will be redistributed to all hospitals across all services
paid under the OPPS through the budget neutral weight scaler. Any
reduction in the growth of OPPS expenditures will result from slower
growth in hospital costs in future years as a result of hospitals
reducing the volume of certain services or finding more efficient ways
to provide care. That potential future savings is one of the purposes
of this packaging initiative and the exploration of episode-based or
encounter-based payments under the OPPS. Similarly, if increased
packaging causes hospitals to be more cautious in their decision making
regarding investing in new equipment or incurring other large capital
expenditures, we view that as a positive result of the policy.
Hospitals make decisions regarding the equipment they buy for general
business reasons, of which payment under the OPPS is only one factor
among many, including, but not limited to, utilization and payments
from other payers and payments from Medicare for IPPS services, which
is the dominant source of Medicare payment for hospital care.
Comment: One commenter asserted that linking growth in volume to
reduced payments is premature, inappropriate, and not supported by
statutory authority. The commenter was particularly concerned about any
methodology that would establish different update factors for different
OPPS service categories, where the update factor is determined in a
manner that takes into account utilization trends. Many commenters
stated that HOPD utilization of services is only marginally within the
control of hospitals. They explained that hospitals provide services
ordered by their medical staff and community physicians, and it would
be inappropriate to penalize hospitals for performing services whose
utilization is not within their control. The commenters believed that
innovation and best practices have increased utilization, not the
provision of excessive services.
Response: Section 1833(t)(2)(F) of the Act requires us to develop a
method of controlling unnecessary increases in the volume of covered
OPS services and section 1833(t)(9)(C) of the Act authorizes us to
adjust the update to the conversion factor if under section
1833(t)(2)(F) of the Act, we determine that there is growth in volume
that exceeds established tolerances. As we indicated in our proposed
rule, we prefer not to take the approach of creating an SGR-type
mechanism that could result in a reduced conversion factor under the
OPPS and that could inadvertently result in actually increasing the
volume of services. We prefer to establish larger packages of services
on which to base OPPS payment in order to create incentives for
hospitals and their physician partners to make thoughtful decisions
regarding what services are medically necessary for their patients and
to continuously reassess how they might be able to provide care more
efficiently. We recognize that decisions regarding the care provided in
HOPDs are not made unilaterally by the hospital, nor are they made
unilaterally by the physician who is ordering the care. While
physicians, rather than hospital staff, may order specific services for
patients, hospitals decide what HOPD services they will and will not
furnish, what drugs and supplies they will or will not buy and from
whom they will buy them, what investments in equipment they will or
will not make, and what programs they will open or close. Certainly,
they make these decisions with significant input from their medical
staff, but it is the hospital administration that makes the final
decisions in this regard. Moreover, hospitals control, to some extent,
the physicians on their medical staff and increasingly employ
physicians to provide services to patients and to supervise the
provision of hospital services. Hence, we do not agree with the
argument that hospitals have no control over the services they furnish
or that they have no influence over the physicians who order the
specific services furnished to their patients.
Comment: Some commenters asked CMS to impose a payment floor to
limit the amount of decline in any APC payment in at least the first
year of implementation as a means of mitigating the effects of no
longer paying separately for the packaged services.
Response: We do not agree that we should impose a payment floor to
limit the amount of decline in any APC payment as a means of mitigating
the effects of no longer paying separately for the packaged services.
The purpose of creating larger payment packages is to create incentives
for hospitals to assess the services they are furnishing to ensure that
they are furnishing only medically necessary services as efficiently as
possible. To establish a payment floor that would artificially inflate
payments for APCs that are declining would reduce what would otherwise
be appropriate increases in payments for other APCs. We believe that
this would be contrary to the stated goal of paying appropriately for
all services through larger payment bundles that are intended to create
incentives for efficiency.
Comment: Several commenters objected to the proposed packaging
approach because they believed that it would be more difficult for new
services to be approved for payment under New Technology APCs. One
commenter believed that it would be difficult for new guidance
services, in particular, to be approved for assignment to a New
Technology APC if CMS considers guidance to be a supportive and
ancillary service rather than a separately paid complete service.
Therefore, the commenter concluded that the proposed packaging not only
packages existing services but creates the potential for new
technologies to not be approved for New Technology APC payment.
Response: We assess applications for New Technology APC placement
on a case-by-case basis. The commenter is correct that, to qualify for
New Technology APC placement, the service must be a complete service,
by which we mean a comprehensive service that stands alone as a
meaningful diagnostic or therapeutic service. To the extent that a
service for which New Technology APC status is being requested is
ancillary and supportive of another service, for example, a new
intraoperative service or a new guidance service, we might not consider
it to be a complete service because its value is as part of an
independent service. However, if the entire, complete service,
including the guidance component of the service, for example, is
``truly new,'' as we explained that term at length in the November 30,
2001 final rule (66 FR 59898) which set forth the criteria for
eligibility for assignment of services to New Technology APCs, we would
consider the new complete procedure for New Technology APC assignment.
[[Page 66622]]
As stated in the November 30, 2001 final rule, by way of examples
provided, ``The use of a new expensive instrument for tissue
debridement or a new, expensive wound dressing does not in and of
itself warrant creation of a new HCPCS code to describe the instrument
or dressing; rather, the existing wound repair code appropriately
describes the service that is being furnished * * * '' (66 FR 59898).
This example may hold for some new guidance technologies as well.
The following discussions separately address each of the seven
categories of items and services for which we proposed to package
payment under the CY 2008 OPPS as part of our packaging proposal and
which we are adopting in this final rule with comment period, with the
modifications discussed under the applicable topic. Many codes that we
proposed to package for CY 2008 could fit into more than one of those
seven categories. For example, CPT code 93325 (Doppler echocardiography
color flow velocity mapping (List separately in addition to codes for
echocardiography)) could be included in both the intraoperative and
image processing categories. Therefore, for organizational purposes,
both to ensure that each code appears in only one category and to
facilitate discussion of our CY 2008 proposed and final policy, we have
created a hierarchy of categories that determines which category each
code appropriately falls into. This hierarchy is organized from the
most clinically specific to the most general type of category. The
hierarchy of categories is as follows: guidance services; image
processing services; intraoperative services; and imaging supervision
and interpretation services. Therefore, while CPT code 93325 may
logically be grouped with either image processing services or
intraoperative services, it is treated as an image processing service
because that group is more clinically specific and precedes
intraoperative services in the hierarchy. We did not believe it was
necessary to include diagnostic radiopharmaceuticals, contrast media,
or observation categories in this list because those services generally
map to only one of those categories. We note that there is no cost
estimation or payment implications related to the assignment of a HCPCS
code for purposes of discussion to any specific category.
Each HCPCS code we discuss in this section has a status indicator
of either ``N'' or ``Q.'' The payment for a HCPCS code with a status
indicator of ``N'' is unconditionally packaged so that its payment is
always incorporated into the payments for the separately paid services
with which it is reported. Payment for a HCPCS code with a status
indicator of ``Q'' is either packaged or separately paid, depending on
the services with which it is reported. Payment for a HCPCS code with a
status indicator of ``Q'' that is ``STVX-packaged'' is packaged unless
the HCPCS code is not reported on the same day with a service that has
a status indicator of ``S,'' ``T,'' ``V,'' or ``X,'' in which case it
would be paid separately. Payment for a HCPCS code with a status
indicator of ``Q'' that is ``T-packaged'' is packaged unless the HCPCS
code is not reported on the same day with a service that has a status
indicator of ``T,'' in which case it would be paid separately. Payment
for a HCPCS code with a status indicator of ``Q'' that is assigned to a
composite APC is packaged into the payment for the composite APC when
the criteria for payment of the composite APC are met.
(1) Guidance Services
We proposed to package payment for HCPCS guidance codes for CY
2008, specifically those codes that are reported for supportive
guidance services, such as ultrasound, fluoroscopic, and stereotactic
navigation services, that aid the performance of an independent
procedure. We performed a broad search for such services, relying upon
the AMA's CY 2007 book of CPT codes and the CY 2007 book of Level II
HCPCS codes, which identified specific HCPCS codes as guidance codes.
Moreover, we performed a clinical review of all HCPCS codes to capture
additional codes that are not necessarily identified as ``guidance''
services but describe services that provide directional information
during the course of performing an independent procedure. For example,
we proposed to package CPT code 61795 (Stereotactic computer-assisted
volumetric (navigational) procedure, intracranial, extracranial, or
spinal (List separately in addition to code for primary procedure))
because we consider it to be a guidance service that provides three-
dimensional information to direct the performance of intracranial or
other diagnostic or therapeutic procedures. We also included HCPCS
codes that existed in CY 2006 but were deleted and were replaced in CY
2007. We included the CY 2006 HCPCS codes because we proposed to use
the CY 2006 claims data to calculate the CY 2008 OPPS median costs on
which the CY 2008 payment rates would be based. Many, although not all,
of the CPT guidance codes we identified are designated in the CPT
coding scheme as add-on codes that are to be reported in addition to
the CPT code for the primary procedure. We also note that there are a
number of CPT codes describing independent surgical procedures that
have code descriptors that indicate that guidance is included in the
code reported for the surgical procedure if it is used and, therefore,
packaged payment is already made for the associated guidance service
under the OPPS. For example, the independent procedure described by CPT
code 55873 (Cryosurgical ablation of the prostate (includes ultrasonic
guidance for interstitial cryosurgical probe placement)) already
includes the ultrasound guidance that may be used. We believed
packaging payment for every guidance service under the OPPS would
provide consistently packaged payment for all these services that are
used to direct independent procedures, even if they are currently
separately reported.
Because these dependent guidance procedures support the performance
of an independent procedure and they are generally provided in the same
operative session as the independent procedure, we believed that it
would be appropriate to package their payment into the OPPS payment for
the independent procedure performed. However, guidance services differ
from some of the other categories of services that we proposed to
package for CY 2008. Hospitals sometimes may have the option of
choosing whether to perform a guidance service immediately preceding or
during the main independent procedure, or not at all, unlike many of
the imaging supervision and interpretation services, for example, which
are generally always reported when the independent procedure is
performed. Once a hospital decides that guidance is appropriate, the
hospital may have several options regarding the type of guidance
service that can be performed. For example, when inserting a central
venous access device, hospitals have the option of using no guidance,
ultrasound guidance, or fluoroscopic guidance, and the selection in any
specific case will depend upon the specific clinical circumstances of
the device insertion procedure. In fact, as we noted in the CY 2008
proposed rule, the historical hospital claims data demonstrated that
various guidance services for the insertion of these devices, which
have historically received packaged payment under the OPPS, are used
frequently for the insertion of vascular access devices.
Thus, we recognized that hospitals have several options regarding
the performance and types of guidance services they use. However, we
believed
[[Page 66623]]
that hospitals utilize the most appropriate form of guidance for the
specific procedure that is performed. We did not want to create payment
incentives to use guidance for all independent procedures or to provide
one form of guidance instead of another. Therefore, by proposing to
package payment for all forms of guidance, we specifically encouraged
hospitals to utilize the most cost effective and clinically
advantageous method of guidance that is appropriate in each situation
by providing them with the maximum flexibility associated with a single
payment for the independent procedure. Similarly, hospitals may
appropriately not utilize guidance services in certain situations based
on clinical indications.
Because guidance services can be appropriately reported in
association with many independent procedures, under our proposed
packaging of guidance services for CY 2008, the costs associated with
guidance services would be mapped to a larger number of independent
procedures than some other categories of codes that we proposed to
package. For example, CPT code 76001 (Fluoroscopy, physician time more
than one hour, assisting a non-radiologic physician (e.g.,
nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy)) can be
reported with a wide range of services. According to the CPT code
descriptor, these procedures include nephrostolithotomy, which may be
reported with CPT code 50080 (Percutaneous nephrostolithotomy or
pyelostolithotomy, with or without dilation, endoscopy, lithotripsy,
stenting, or basket extraction; up to 2 cm), and endoscopic retrograde
cholangiopancreatography, which may be reported with CPT code 43260
(Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic,
with or without collection of specimen(s) by brushing or washing
(separate procedure)). Therefore, the cost of the fluoroscopic guidance
would be reflected in the payment for each of these independent
services, in addition to numerous other procedures, rather than in the
payment for only one or two independent services, as is the case for
some of the other categories of codes that we proposed to package for
CY 2008.
In addition, because independent procedures such as CPT code 20610
(Arthrocentesis, aspiration and/or injection; major joint or bursa
(e.g., shoulder, hip, knee joint, subacromial bursa)) may be reported
with or without guidance, the cost for the guidance will be reflected
in the median cost for the independent procedure as a function of the
frequency that guidance is reported with that procedure. As we stated
previously, the median cost for a particular independent procedure
generally will be higher as a result of added packaging, but also could
change little or be lower because median costs typically do not reflect
small distributional changes and because changes to the packaged HCPCS
codes affect both the number and composition of single bills and the
mix of hospitals contributing those single bills. In fact, the CY 2007
CPT book indicates that if guidance is performed with CPT code 20610,
it may be appropriate to bill CPT code 76942 (Ultrasonic guidance for
needle placement (e.g., biopsy, aspiration, injection, localization
device), imaging supervision and interpretation); 77002 (Fluoroscopic
guidance for needle placement (e.g., biopsy, aspiration, injection,
localization device)); 77012 (Computed tomography guidance for needle
placement (e.g., biopsy, aspiration, injection, localization device),
radiological supervision and interpretation); or 77021 (Magnetic
resonance guidance for needle placement (e.g., for biopsy, needle
aspiration, injection, or placement of localization device)
radiological supervision and interpretation). The CY 2007 CPT book also
implies that it is not always clinically necessary to use guidance in
performing an arthrocentesis described by CPT code 20610.
The guidance procedures that we proposed to package for CY 2008
vary in their resource costs. Resource cost was not a factor we
considered when proposing to package guidance procedures. Notably, most
of the guidance procedures are relatively low cost in comparison to the
independent services they frequently accompany.
The codes we proposed to identify as guidance codes for CY 2008
that would receive packaged payment were listed in Table 8 of the CY
2008 proposed rule (72 FR 42657). (Table 10 in this final rule with
comment period contains a comprehensive list of all codes in the final
seven categories for services that are packaged for CY 2008.)
Several of these codes, including CPT code 76937 (Ultrasound
guidance for vascular access requiring ultrasound evaluation of
potential access sites, documentation of selected vessel patency,
concurrent real time ultrasound visualization of vascular needle entry,
with permanent recording and reporting (List separately in addition to
code for primary procedure)), were already unconditionally (that is,
always) packaged under the CY 2007 OPPS, where they have been assigned
status indicator ``N.'' Payment for these services is currently made as
part of the payment for the separately payable, independent services
with which they are billed. No separate payment is made for services
that we have assigned to status indicator ``N.'' We did not propose
status indicator changes for the five guidance procedures that were
unconditionally packaged for CY 2007.
We proposed to change the status indicators for 31 guidance
procedures from separately paid to unconditionally packaged (status
indicator ``N'') for the CY 2008 OPPS. We believed that these services
are always integral to and dependent upon the independent services that
they support and, therefore, their payment would be appropriately
packaged because they would generally be performed on the same date and
in the same hospital as the independent services.
We proposed to change the status indicator for one guidance
procedure from separately paid to conditionally packaged (status
indicator ``Q''), and to treat it as a ``special'' ``packaged code for
the CY 2008 OPPS, specifically, CPT code 76000 (Fluoroscopy (separate
procedure), up to 1 hour physician time, other than 71023 or 71034
(e.g., cardiac fluoroscopy)). This code was discussed in the past with
the Packaging Subcommittee of the APC Panel, which determined that,
consistent with its code descriptor as a separate procedure, this
procedure could sometimes be provided alone, without any other services
on the claim. We believe that this procedure will usually be provided
by a hospital as guidance in conjunction with another significant
independent procedure on the same date of service but may occasionally
be provided without another independent service. As a ``special''
packaged code, if the fluoroscopy service were billed without any other
service assigned status indicator ``S,'' ``T,'' ``V,'' or ``X''
reported on the same date of service, under our proposal we would not
treat the fluoroscopy procedure as a dependent service for purposes of
payment. If we were to unconditionally package payment for this
procedure, treating it as a dependent service, hospitals would receive
no payment at all when providing this service alone, although the
procedure would not be functioning as a guidance service in that case.
However, according to our proposal, its conditionally packaged status
with its designation as a ``special'' packaged code would allow payment
to be provided for this ``Q'' status fluoroscopy
[[Page 66624]]
procedure, in which case it would be treated as an independent service
under these limited circumstances. On the other hand, when the
fluoroscopy service is furnished as a guidance procedure on the same
day and in the same hospital as independent, separately paid services
that are assigned status indicator ``S,'' ``T,'' ``V,'' or ``X,'' we
proposed to package payment for it as a dependent service. In all
cases, we proposed that hospitals that furnish independent services on
the same date as dependent guidance services must bill them all on the
same claim. We believed that when dependent guidance services and
independent services are furnished on the same date and in the same
facility, they are part of a single complete hospital outpatient
service that is reported with more than one HCPCS code, and no separate
payment should be made for the guidance service that supports the
independent service.
The estimated overall impact of these changes presented in section
XXII.B. of the proposed rule (section XXIV.B. in this final rule with
comment period) was based on the assumption that hospital behavior
would not change with regard to when these dependent services are
performed on the same date and by the same hospital that performs the
independent services. To the extent that hospitals could change their
behavior and perform the guidance services more or less frequently, on
subsequent dates, or at settings outside of the hospital, the data
would show such a change in practice in future years and that change
would be reflected in future budget neutrality adjustments. However,
with respect to guidance services in particular, we believe that
hospitals are limited in the extent to which they could change their
behavior with regard to how they furnish these services. By their
definition, these guidance services generally must be furnished on the
same date and at the same operative location as the independent
procedure in order for the guidance service to meaningfully contribute
to the treatment of the patient in directing the performance of the
independent procedure. We do not believe the clinical characteristics
of the guidance services will change in the immediate future.
As we indicated earlier, in all cases, we proposed that hospitals
that furnish the guidance service on the same date as the independent
service must bill both services on the same claim. We indicated that we
expected to carefully monitor any changes in billing practices on a
service-specific and hospital-specific basis to determine whether there
is reason to request that QIOs review the quality of care furnished or
to request that Program Safeguard Contractors review the claims against
the medical record.
During the September 2007 APC Panel meeting, the Panel recommended
that CMS finalize the proposal to package guidance services, with the
exception of radiation oncology guidance procedures.
We received many public comments on our proposal to package
guidance services for CY 2008. A summary of the public comments and our
responses follow.
Comment: Many commenters requested that, if CMS elected to finalize
the packaging status of the guidance codes proposed for packaging, CMS
exclude radiation oncology guidance procedures, in accordance with the
APC Panel recommendation. Specifically, many commenters requested that
CMS pay separately for CPT codes 76950 (Ultrasonic guidance for
placement of radiation therapy fields); 76965 (Ultrasonic guidance for
interstitial radioelement application); 77014 (Computed tomography
guidance for placement of radiation therapy fields); 77417 (Therapeutic
radiology port film(s)); and 77421 (Stereoscopic X-ray guidance for
localization of target volume for the delivery of radiation therapy).
The commenters were concerned that packaging radiation oncology
guidance procedures would encourage hospitals to decrease utilization
of advanced technologies for localization used in radiation oncology
treatment delivery. The commenters noted that packaging payment for
radiation oncology guidance services offers a financial incentive to
those hospitals that use little or no daily localization when providing
radiation therapy. One commenter believed that packaging payment for
these guidance services encourages hospitals to use older, less
effective technologies, thereby discouraging development of new, more
effective technologies. Another commenter noted that if hospitals are
discouraged from using new technologies due to low payment rates, it
will take many years to gather robust cost data that reflect these new
technologies, likely even longer than New Technology APC and pass-
through payments are available for new technologies.
Response: After reviewing these public comments, considering the
recommendation of the APC Panel, and ensuring that CMS clinical staff
analyzed the content of these comments, we have decided to finalize our
proposal to package these guidance services, as proposed. These
services are ancillary and dependent in relation to the radiation
therapy services with which they are most commonly furnished. Moreover,
there are no unique clinical aspects to these radiation oncology
guidance services that would differentiate them from other guidance
services. Consistent with the principles of a prospective payment
system, in some cases, payment in an individual case exceeds the
average costs, and in other cases payment is less than the average
cost, but on balance, payment should approximate the relative cost of
the average case. We do not believe that beneficiary access to care
will be harmed by increased packaging. We believe that packaging will
create incentives for hospitals and their physician partners to work
together to establish appropriate protocols that will eliminate
unnecessary services where they exist and institutionalize approaches
to providing necessary services more efficiently. Therefore, we see no
basis for treating radiation oncology services differently from other
guidance services that are ancillary and dependent to the procedure
that they facilitate.
Comment: Many commenters were concerned with the proposal to
package payment for electrodiagnostic guidance for chemodenervation
procedures, specifically, CPT codes 95873 (Electrical stimulation for
guidance in conjunction with chemodenervation (List separately in
addition to code for primary procedure)), and 95874 (Needle
electromyography for guidance in conjunction with chemodenervation
(List separately in addition to code for primary procedure)). The
commenters indicated that chemodenervation involves the injection of
chemodenervation agents, such as botulinum toxin, to control the
symptoms associated with dystonia and other disorders. According to the
commenters, physicians often, but not always, use electromyography or
electrical stimulation guidance to guide the needle to the most
appropriate location. The commenters were concerned that the proposal
to package payment for these guidance services may discourage
utilization of this particular form of guidance, even when medically
appropriate. Several commenters noted that the CY 2008 proposed payment
rate for the injection and the associated guidance is a 15 percent
decrease from the CY 2007 payment rate. Most commenters requested that
CMS pay separately for electrodiagnostic guidance, several of whom
specified that CMS assign the
[[Page 66625]]
three chemodenervation procedures to their own APC. The commenters
noted that even if the median cost for the chemodenervation procedures
increased, the payment rate would not increase because chemodenervation
procedures are only a small proportion of all claims in their proposed
APC 0204 (Level I Nervous System Injections). Several other commenters
stated that the median costs for the chemodenervation procedures do not
reflect the full cost of the guidance because the guidance is performed
with the procedure infrequently.
Response: We note that the cost of the chemodenervation guidance
services will be reflected in the median cost for the independent HCPCS
code as a function of the frequency that chemodenervation services are
reported with that particular HCPCS code. As noted above, we recognize
that, in some cases, supportive and ancillary dependent services are
furnished at high frequency with independent services, and in other
cases, they are furnished with independent services at a low frequency.
We believe that packaging should reflect the reality of how services
are furnished. While the commenters are correct that the
chemodenervation procedures reflect only approximately 10 percent of
the services that comprise APC 0204, we note that they appropriately
map to this APC both clinically and in terms of resource use. If the
median costs for the individual chemodenervation procedures were to
change dramatically, based on resource cost data, we would review these
services as part of our annual review process to determine if a
different APC were more appropriate. We also note that if these three
chemodenervation procedures were mapped to their own APC, the estimated
median cost of the APC would be in the same general cost range as the
current median cost for APC 0204. Therefore, it is unnecessary to map
these three services to their own APC for CY 2008.
Comment: Several commenters requested that CMS clarify how the DRA
imaging cap for services paid under the MPFS would be applied to
services that are packaged under the OPPS.
Response: If an imaging service is packaged under the OPPS, the DRA
cap on the technical component payment for that service under the MPFS
is not applicable.
Comment: Many commenters supported the proposal to package each of
the guidance services that we identified in the proposed rule. The
commenters also gave specific comments related to almost every guidance
code that we proposed to package. In general, each commenter requested
that we pay separately for several of the guidance codes that we
proposed to package. The commenters expressed concern in several areas,
specifically, that insufficient payment rates would discourage new
technologies; that guidance services used infrequently with specific
services contribute very little to the payment rates for those
services; that the expected decrease in utilization for guidance
services could ultimately lead to increased costs, as a result of worse
patient outcomes; that packaged payment under the OPPS and separate
payment under the MPFS leads to payment disparity; and, in general,
that the lack of published crosswalks makes it difficult to analyze the
specific effects of this policy.
Response: We note that we did not receive any unique arguments
specific to any particular code. We received many similar public
comments regarding all the categories of codes that we proposed for
packaged payment. Therefore, we have responded to these general
comments above in section II.A.4.c. of this final rule with comment
period. In light of the public comments we received, our clinical
advisors reassessed every guidance code on the list to ensure that it
was still appropriate for packaged payment.
For CY 2008, we are finalizing the CY 2008 proposal, without
modification, to package payment for all guidance services for CY 2008.
We are partially accepting the APC Panel recommendation. Specifically,
we are packaging all guidance services for CY 2008, including radiation
oncology services. The guidance codes that are packaged for CY 2008 are
identified and displayed in Table 10 of this final rule with comment
period. These services are assigned status indicator ``N'' to indicate
their unconditional packaging, with the exception of CPT code 76000,
which is an ``STVX-packaged'' code assigned status indicator ``Q.''
(2) Image Processing Services
We proposed to package payment for ``image processing'' HCPCS codes
for CY 2008, specifically those codes that are reported as supportive
dependent services to process and integrate diagnostic test data in the
development of images, performed concurrently or after the independent
service is complete. We performed a broad search for such services,
relying upon the AMA's CY 2007 book of CPT codes and the CY 2007 book
of Level II HCPCS codes, which identified specific codes as
``processing'' codes. In addition, we performed a clinical review of
all HCPCS codes to capture additional codes that we consider to be
image processing. For example, we proposed to package payment for CPT
code 93325 (Doppler echocardiography color flow velocity mapping (List
separately in addition to codes for echocardiography)) because it is an
image processing procedure, even though the code descriptor does not
specifically indicate it as such.
An image processing service processes and integrates diagnostic
test data that were captured during another independent procedure,
usually one that is separately payable under the OPPS. The image
processing service is not necessarily provided on the same date of
service as the independent procedure. In fact, several of the image
processing services that we proposed to package for CY 2008 do not need
to be provided face-to-face with the patient in the same encounter as
the independent service. While this approach to service delivery may be
administratively advantageous from a hospital's perspective, providing
separate payment for each image processing service whenever it is
performed is not consistent with encouraging value-based purchasing
under the OPPS. We believed it was important to package payment for
supportive dependent services that accompany independent services but
that may not need to be provided face-to-face with the patient in the
same encounter because the supportive services utilize data that were
collected during the preceding independent services and packaging their
payment encourages the most efficient use of hospital resources. We are
particularly concerned with any continuance of current OPPS payment
policies that could encourage certain inefficient and more costly
service patterns. As stated above, packaging encourages hospitals to
establish protocols that ensure that services are furnished only when
they are medically necessary and to carefully scrutinize the services
ordered by practitioners to minimize unnecessary use of hospital
resources. Our standard methodology to calculate median costs packages
the costs of dependent services with the costs of independent services
on ``natural'' single claims across different dates of service, so we
are confident that we would capture the costs of the supportive image
processing services for ratesetting when they are packaged according to
our CY 2008 proposal, even if they were provided on a different date
than the independent procedure.
We listed the image processing services that we proposed to be
packaged for CY 2008 in Table 10 in the
[[Page 66626]]
CY 2008 proposed rule (72 FR 42659). As these services support the
performance of an independent service, we believe it would be
appropriate to package their payment into the OPPS payment for the
independent service provided.
As many independent services may be reported with or without image
processing services, the cost of the image processing services will be
reflected in the median cost for the independent HCPCS code as a
function of the frequency that image processing services are reported
with that particular HCPCS code. Again, while the median cost for a
particular independent procedure generally will be higher as a result
of added packaging, it could also change little or be lower because
median costs typically do not reflect small distributional changes and
because changes to the packaged HCPCS codes affect both the number and
composition of single bills and the mix of hospitals contributing those
single bills. For example, CPT code 70450 (Computed tomography, head or
brain; without contrast material) may be provided alone or in
conjunction with CPT code 76376 (3D rendering with interpretation and
reporting of computed tomography, magnetic resource imaging,
ultrasound, or other tomographic modality; not requiring image post-
processing on an independent workstation). In fact, CPT code 70450 was
provided approximately 1.5 million times based on CY 2008 proposed rule
claims data. CPT code 76376 was provided with CPT code 70450 less than
2 percent of the total instances that CPT code 70450 was billed.
Therefore, as the frequency of CPT code 76376 provided in conjunction
with CPT code 70450 increases, the median cost for CPT code 70450 would
be more likely to reflect that additional cost.
The image processing services that we proposed to package vary in
their hospital resource costs. Resource cost was not a factor we
considered when we proposed to package supportive image processing
services. Notably, the majority of image processing services that we
proposed to package have modest median costs in relationship to the
cost of the independent service that they typically accompany.
Several of these codes, including CPT code 76350 (Subtraction in
conjunction with contrast studies), are already unconditionally (that
is, always) packaged under the CY 2007 OPPS, where they have been
assigned status indicator ``N.'' Payment for these services is made as
part of the payment for the separately payable, independent services
with which they are billed. No separate payment is made for services
that we have assigned status indicator ``N.'' We did not propose status
indicator changes for the four image processing services that were
unconditionally packaged for CY 2007.
We proposed to change the status indicator for seven image
processing services from separately paid to unconditionally packaged
(status indicator ``N'') for the CY 2008 OPPS. We believe that these
services are always integral to and dependent upon the independent
service that they support and, therefore, their payment would be
appropriately packaged.
The estimated overall impact of these changes presented in section
XXII.B. of the proposed rule (section XXIV.B. of this final rule with
comment period) was based on the assumption that hospital behavior
would not change with regard to when these dependent image processing
services are performed on the same date and by the same hospital that
performs the independent services. To the extent that hospitals could
change their behavior and perform the image processing services more or
less frequently, the data would show such a change in practice in
future years and that change would be reflected in future budget
neutrality adjustments.
As we indicated earlier, in all cases, we provided that hospitals
that furnish the image processing procedure in association with the
independent service must bill both services on the same claim. We
indicated that we expected to carefully monitor any changes in billing
practices on a service-specific and hospital-specific basis to
determine whether there is reason to request that QIOs review the
quality of care furnished or to request that Program Safeguard
Contractors review the claims against the medical record.
The APC Panel recommended that all image processing services be
packaged as proposed in the proposed rule.
We received a number of public comments on our proposal to package
image processing service for CY 2008. A summary of the public comments
and our responses follow.
Comment: Many commenters were concerned with the proposal to
package payment for CPT code 93325 (Doppler echocardiography color flow
velocity mapping (List separately in addition to codes for
echocardiography)). The commenters noted that this service is often
critical to decisionmaking and consumes significantly greater resources
than the general echocardiography study process. Several commenters
noted that the AMA is planning to revise this CPT code for CY 2009, and
that changing the payment status of this code may confuse hospital
coding staff. Some commenters requested that CMS make no changes to the
payment status of this code until this code's descriptor has been
revised by the AMA, while others requested that CMS instruct hospitals
not to use the new CPT code that will be created by the AMA.
Response: We acknowledge that this service may be an important
clinical tool that is critical to decisionmaking. However, we continue
to believe that packaged payment is appropriate for this dependent
service that must, per the CY 2007 CPT book, be provided in conjunction
with echocardiography. In fact, packaging the status of this code may
make it easier to crosswalk the data from this code to the new CPT code
that the AMA may create for CY 2009. We see no compelling reason to
postpone packaging this service until CY 2009.
Comment: One commenter requested that CMS pay separately for HCPCS
code G0288 (Reconstruction, computed tomographic angiography of aorta
for surgical planning for vascular surgery) because it is different
than the other image processing codes proposed for packaged payment.
The commenter stated that the service is often an out-sourced service
purchased by the hospital. The commenter was particularly concerned
that hospitals would no longer continue to purchase this service if
insufficient payment was provided. Another commenter requested separate
payment for CPT code 95957 (Digital analysis of electroencephalogram
(EEG) (eg, for epileptic spike analysis)). The commenter stated that
this service is often performed on a different day than the EEG and by
a technologist other than the one who performed the EEG.
Response: As noted above, we believe it is important to package
payment for supportive dependent services that may not need to be
provided face-to-face with the patient in the same encounter as the
independent service. Packaging payment for supportive services that
utilize data that were collected during the preceding independent
services encourages the most efficient use of hospital resources. In
fact, as part of our proposed CY 2008 packaging approach, we also
proposed to unconditionally package payment in CY 2008 for several
other image processing services that are not always performed face-to-
face, including 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
[[Page 66627]]
film radiographic images, chest radiograph(s), performed concurrent
with primary interpretation); 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); and CPT
code 76377 (3D rendering with interpretation and reporting of computed
tomography, magnetic resource imaging, ultrasound, or other tomographic
modality; requiring image postprocessing on an independent
workstation).
We also believe it is likely that a hospital that performed the
computed tomographic angiography diagnostic procedure but does not have
the technology necessary to provide the preoperative image
reconstruction would send the results to another hospital for
performance of the reconstruction. In this situation, the second
hospital would be providing the reconstruction under arrangement and,
therefore, at least one service provided by the first hospital would be
separately paid. We believe that packaged payment for image
reconstruction under a prospective payment methodology for hospital
outpatient services is most appropriate. The same situation occurs when
hospitals provide the service described by CPT code 95957. We proposed
to unconditionally package payment for HCPCS code G0288 and CPT code
95957 for CY 2008, fully consistent with the packaging approach for the
CY 2008 OPPS. Because HCPCS code G0288 and CPT code 95957 are
supportive ancillary services that fit into the image processing
category, and we proposed to package payment for all image processing
services for CY 2008, we believe it is appropriate to unconditionally
package payment associated with these codes. Specifically, we
determined that these services are dependent services that are integral
to independent services, in this case, the computed tomographic
angiography and the EEG that we would expect to be provided. Even if
the imaging process services were provided on another day than the
independent services, our packaging methodology packages costs across
dates of service on ``natural'' single claims, so that the costs of
image process services would be captured.
For CY 2008, we are finalizing the packaged status of HCPCS code
G0288 and CPT code 95957, as listed in Table 10 of the proposed rule.
We note an inadvertent error in Addendum B to the proposed rule.
However, Table 10 of the proposed rule listed the accurate proposed
payment status of HCPCS code G0288.
Comment: Many commenters supported the proposal to package each of
the image processing services that was identified in the proposed rule.
Numerous other commenters requested that CMS postpone packaging all the
packaged codes included in all categories of the proposal until
additional data were provided to the public. These commenters also
submitted specific comments related to almost every image processing
code that CMS proposed to package. The commenters expressed concern in
several areas, specifically, that what they considered to be
insufficient payment rates would discourage new technologies; that
image processing services used infrequently with specific services
contribute very little to the payment rates for those services; that
the expected decrease in utilization for image processing services
could ultimately lead to increased costs, as a result of worse patient
outcomes; and in general, that the lack of published crosswalks makes
it difficult to analyze the specific effects of this policy.
Several commenters requested a crosswalk that specified how the
packaged costs were allocated from each dependent code to each
independent code. Other commenters requested that CMS create edits to
ensure that costs are appropriately mapped to independent codes.
Several commenters requested that CMS consider resource cost when
determining which codes to package. The commenters were concerned that
what they considered to be insufficient payment would create a
disincentive for hospitals to adopt new technology.
Response: We note that we did not receive any unique arguments
specific to any particular code. These comments are similar to those
received for all the categories of codes that we proposed for packaged
payment. Therefore, we have responded to these general comments above
in section II.A.4.c. of this final rule with comment period. In light
of the public comments we received, our clinical advisors reassessed
every image processing code on the list to ensure that it was still
appropriate for packaged payment.
We received one comment related to CPT codes 0174T and 0175T. The
comment summary and response related to those codes are located in
section II.A.4.e. of this final rule with comment period.
For CY 2008, we are finalizing our proposal, without modification,
to unconditionally package the payment for all imaging processing codes
listed in Table 10 of this final rule with comment period. We are
accepting the APC Panel recommendation to package all image processing
services. These services are assigned status indicator ``N'' to
indicate their unconditional packaging.
(3) Intraoperative Services
We proposed to package payment for ``intraoperative'' HCPCS codes
for CY 2008, specifically those codes that are reported for supportive
dependent diagnostic testing or other minor procedures performed during
independent procedures. We performed a broad search for possible
intraoperative HCPCS codes, relying upon the AMA's CY 2007 book of CPT
codes and the CY 2007 book of Level II HCPCS codes, to identify
specific codes as ``intraoperative'' codes. Furthermore, we performed a
clinical review of all HCPCS codes to capture additional supportive
diagnostic testing or other minor intraoperative or intraprocedural
codes that are not necessarily identified as ``intraoperative'' codes.
For example, we proposed to package payment for CPT code 95955
(Electroencephalogram (EEG) during nonintracranial surgery (e.g.,
carotid surgery)) because it is a minor intraoperative diagnostic
testing procedure even though the code descriptor does not indicate it
as such. Although we use the term ``intraoperative'' to categorize
these procedures, we also have included supportive dependent services
in this group that are provided during an independent procedure,
although that procedure may not necessarily be a surgical procedure.
These dependent services clearly fit into this category because they
are provided during, and are integral to, an independent procedure,
like all the other intraoperative codes, but the independent procedure
they accompany may not necessarily be a surgical procedure. For
example, we proposed to package HCPCS code G0268 (Removal of impacted
cerumen (one or both ears) by physician on same date of service as
audiologic function testing). While specific audiologic function
testing procedures are not surgical procedures performed in an
operating room, they are independent procedures that are separately
payable under the OPPS, and HCPCS code G0268 is a supportive dependent
service always provided in association with one of these independent
services. All references to ``intraoperative'' below refer to services
that are usually or always provided during a surgical procedure or
other independent procedure.
[[Page 66628]]
By definition, a service that is performed intraoperatively is
provided during and, therefore, on the same date of service as another
procedure that is separately payable under the OPPS. Because these
intraoperative services support the performance of an independent
procedure and they are provided in the same operative session as the
independent procedure, we believed it would be appropriate to package
their payment into the OPPS payment for the independent procedure
performed. Therefore, we did not propose to package payment for CY 2008
for those diagnostic services, such as CPT code 93005
(Electrocardiogram, routine ECG with at least 12 leads; tracing only,
without interpretation and report) that are sometimes or only rarely
performed and reported as supportive services in association with other
independent procedures. Instead, we proposed to include those HCPCS
codes that are usually or always performed intraoperatively, based upon
our review of the codes described above. The intraoperative services
that we proposed to package vary in hospital resource costs. Resource
cost was not a factor we considered when determining which supportive
intraoperative procedures to package.
The codes we proposed to identify as intraoperative services for CY
2008 that would receive packaged payment under the OPPS were listed in
Table 12 of the proposed rule (72 FR 42661 through 42662).
Several of these codes, including CPT code 93640
(Electrophysiologic 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 the time of initial implantation or
replacement), are already unconditionally (that is, always) packaged
under the CY 2007 OPPS, where they have been assigned status indicator
``N.'' Payment for these services is made through the payment for the
separately payable, independent services with which they are billed. No
separate payment is made for services that we have assigned status
indicator ``N.'' We did not propose status indicator changes for the
five diagnostic intraoperative services that were unconditionally
packaged for CY 2007.
We proposed to change the status indicator for 34 intraoperative
services from separately paid to unconditionally packaged (status
indicator ``N'') for the CY 2008 OPPS. As stated in the CY 2008
proposed rule, we believe that these services are always integral to
and dependent upon the independent services that they support and,
therefore, their payment would be appropriately packaged because they
would generally be performed on the same date and in the same hospital
as the independent services.
We also proposed to change the status indicator for one
intraoperative procedure from unconditionally packaged to conditionally
packaged (status indicator ``Q'') as a ``special'' packaged code for
the CY 2008 OPPS, specifically, CPT code 0126T (Common carotid intima-
media thickness (IMT) study for evaluation of atherosclerotic burden or
coronary heart disease risk factor assessment). This code was discussed
in the past with the Packaging Subcommittee of the APC Panel, which
determined that, consistent with its code descriptor as a separate
procedure, this procedure could sometimes be provided alone, without
any other OPPS services on the claim. We believed that this procedure
would usually be provided by a hospital in conjunction with another
independent procedure on the same date of service but may occasionally
be provided without another independent service. As a ``special''
packaged code, if the study were billed without any other service
assigned status indicator ``S,'' ``T,'' ``V,'' or ``X'' reported on the
same date of service, under our proposal we proposed not to treat the
IMT study as a dependent service for purposes of payment. If we were to
continue to unconditionally package payment for this procedure,
treating it as a dependent service, hospitals would receive no payment
at all when providing this service alone, although the procedure would
not be functioning as an intraoperative service in that case. However,
according to our proposal, its conditionally packaged status as a
``special'' packaged code would allow payment to be provided for this
``Q'' status IMT study when provided alone, in which case it would be
treated as an independent service under these limited circumstances. On
the other hand, when this service is furnished as an intraoperative
procedure on the same day and in the same hospital as independent,
separately paid services that are assigned status indicator ``S,''
``T,'' ``V,'' or ``X,'' we proposed to package payment for it as a
dependent service. In all cases, we proposed that hospitals that
furnish independent services on the same date as this IMT procedure
must bill them all on the same claim. We believed that when dependent
and independent services are furnished on the same date and in the same
facility, they are part of a single complete hospital outpatient
service that is reported with more than one HCPCS code, and no separate
payment should be made for the intraoperative procedure that supports
the independent service.
The estimated overall impact of these changes presented in section
XXII.B. of the proposed rule (section XXIV.B. of this final rule with
comment period) was based on the assumption that hospital behavior
would not change with regard to when these intraoperative dependent
services are performed on the same date and by the same hospital that
performs the independent services. To the extent that hospitals could
change their behavior and perform the intraoperative services more or
less frequently, on subsequent dates, or at settings outside of the
hospital, the data would show such a change in practice in future years
and that change would be reflected in future budget neutrality
adjustments. However, with respect to intraoperative services in
particular, we believed that hospitals are limited in the extent to
which they could change their behavior with regard to how they furnish
these services. By their definition, these intraoperative services
generally must be furnished on the same date and at the same operative
location as the independent procedure in order to be considered
intraoperative. For these codes, we assume that both the dependent and
independent services would be furnished on the same date in the same
hospital, and hospitals should bill them on the same claim with the
same date of service.
As we indicated earlier, in all cases we provided that hospitals
that furnish the intraoperative procedure on the same date as the
independent service must bill both services on the same claim. We
expect to carefully monitor any changes in billing practices on a
service-specific and hospital-specific basis to determine whether there
is reason to request that QIOs review the quality of care furnished or
to request that Program Safeguard Contractors review the claims against
the medical record.
During the September 2007 APC Panel meeting, the Panel recommended
that CMS finalize the proposal to package intraoperative services and
that CMS consider assigning status indicator ``Q'' to CPT code 96020
(Neurofunctional testing selection and administration during
noninvasive imaging functional brain mapping, with test administered
entirely by a physician or psychologist, with review of test results
and report).
We received many public comments on our proposal to package
[[Page 66629]]
intraoperative services for CY 2008. A summary of the public comments
and our responses follow.
Comment: Several commenters requested that CMS change the status of
CPT code 96020 to conditionally packaged or separately payable instead
of finalizing the proposal to unconditionally package this code.
According to the commenters, functional brain mapping is often
performed prior to epilepsy surgery. The commenters noted that
functional brain mapping is performed by staff other than the
neurologist or neuropsychologist who performs the accompanying
functional MRI, reported with CPT code 70555 (Magnetic resonance
imaging, brain, functional MRI; requiring physician or psychologist
administration of entire neurofunctional testing). One commenter
clarified that functional MRI is more commonly performed without
functional brain mapping. If CPT code 96020 were conditionally
packaged, the commenter believed that separate payment should be made
for CPT code 96020 when it was provided with the functional MRI.
Another commenter stated that functional brain mapping is a separate
service from the functional MRI, and therefore should not be packaged.
Response: The AMA 2007 CPT book specifically states that CPT code
70555 can only be reported if CPT code 96020 is also performed. CPT
code 70555 is separately payable under the CY 2008 OPPS. Therefore,
whenever CPT code 70555, the independent procedure, is billed with CPT
code 96020, the dependent procedure, the payment associated with CPT
code 96020 is appropriately packaged into the payment for CPT code
70555. Even if CPT code 96020 were conditionally packaged, separate
payment would not be made when it was billed with CPT code 70555. In
addition, we believe that functional brain mapping is never provided to
a patient as a sole service. Instead, it is always provided in
conjunction with a functional MRI. Therefore, we continue to believe
that unconditional packaging is appropriate for CPT code 96020.
Comment: Many commenters requested that CMS continue to pay
separately for intravascular ultrasound (IVUS), fractional flow reserve
(FFR), and intracardiac echocardiography (ICE) reported with CPT codes
37250 (Intravascular ultrasound (non-coronary vessel) during diagnostic
evaluation and/or therapeutic intervention; initial vessel (List
separately in addition to code for primary procedure)); 37251
(Intravascular ultrasound (non-coronary vessel) during diagnostic
evaluation and/or therapeutic intervention; each additional vessel
(List separately in addition to code for primary procedure)); 75946
(Intravascular ultrasound (non coronary vessel), radiological
supervision and interpretation; each additional non-coronary vessel
(List separately in addition to code for primary procedure)); 92978
(Intravascular ultrasound (coronary vessel or graft) during diagnostic
evaluation and/or therapeutic intervention including imaging
supervision, interpretation and report; initial vessel (List separately
in addition to code for primary procedure)); 92979 (Intravascular
ultrasound (coronary vessel or graft) during diagnostic evaluation and/
or therapeutic intervention including imaging supervision,
interpretation and report; each additional vessel (List separately in
addition to code for primary procedure)); 93571 (Intravascular Doppler
velocity and/or pressure derived coronary flow reserve measurement
(coronary vessel or graft) during coronary angiography including
pharmacologically induced stress; initial vessel (List separately in
addition to code for primary procedure)); 93572 (Intravascular Doppler
velocity and/or pressure derived coronary flow reserve measurement
(coronary vessel or graft) during coronary angiography including
pharmacologically induced stress; each additional vessel (List
separately in addition to code for primary procedure)); and 93662
(Intracardiac echocardiography during therapeutic/diagnostic
intervention, including imaging supervision and interpretation (List
separately in addition to code for primary procedure)).
The commenters noted that, while use of these procedures often
results in better patient outcomes and reduced need for subsequent
procedures, they are only provided to a small proportion of patients
who undergo stenting, angioplasty, and other related services. A number
of commenters specified that IVUS is performed on 1 to 20 percent of
patients who undergo a related diagnostic or therapeutic intervention,
using Medicare claims and internal hospital assessments. Therefore, the
commenters stated that the costs for IVUS, FFR, and ICE do not affect
the payment rates for the independent procedures in a significant way,
if at all. In addition, the commenters noted that IVUS, in particular,
involves high resource costs because of expensive capital equipment,
significant labor cost, and disposable supplies. Several commenters
noted that the CY 2005 OPPS data included a median cost of $2,000 for
IVUS, with approximately $800 of those costs related solely to the
device component. One commenter stated that IVUS may be performed in
conjunction with a diagnostic procedure that maps to an APC such as
0080 (Diagnostic Cardiac Catheterization); 0267 (Level III Diagnostic
and Screening Ultrasound); or 0280 (Level III Angiography and
Venography), rather than a major therapeutic procedure such as stenting
or angioplasty, resulting in a total payment of $150 to $2,500, which
would not cover the hospital's costs. Other commenters elaborated on
the costs associated with ICE, which is reported with the corresponding
independent services described by CPT codes 93621 (Comprehensive
electrophysiologic evaluation including insertion and repositioning of
multiple electrode catheters with induction or attempted induction of
arrhythmia; with left atrial pacing and recording from coronary sinus
or left atrium (List separately in addition to code for primary
procedure)); 93622 (Comprehensive electrophysiologic evaluation
including insertion and repositioning of multiple electrode catheters
with induction or attempted induction of arrhythmia; with left
ventricular pacing and recording (List separately in addition to code
for primary procedure)); 93651 (Intracardiac catheter ablation of
arrhythmogenic focus; for treatment of supraventricular tachycardia by
ablation of fast or slow atrioventricular pathways, accessory
atrioventricular connections or other atrial foci, singly or in
combination); and 93652 (Intracardiac catheter ablation of
arrhythmogenic focus; for treatment of ventricular tachycardia), in
only 5 percent of the claims involving the above procedures. The
commenters also noted that only 14 percent of hospitals billed ICE with
the CPT codes listed above, indicating that the impact of packaged
payment will affect a subset of hospitals who invested in this capital
equipment. One commenter noted that IVUS and ICE are clearly not
integral to any independent procedure because they are used
infrequently. Other commenters noted that costs will be improperly
allocated to hospitals that perform the independent procedure,
regardless of whether they purchased the equipment for the dependent
procedure. One commenter disputed describing FFR services as
``ancillary'' and stated that they are ``decisional'' and therefore
should not be packaged. The commenters expressed concern that packaged
payment will create a
[[Page 66630]]
significant financial disincentive to provide these services. The
commenters also noted that these procedures should not be described as
``intraoperative'' because they precede the independent procedure, and
may even result in canceling the independent procedure. One commenter
requested that CMS assign status indicator ``Q'' to CPT codes 93571 and
93572. On the other hand, several commenters specified that these
services are not stand alone procedures. One commenter stated that it
is illegal under section 1833(t)(2)(G) of the Act to package payment
for IVUS and FFR, which do not use contrast agents, into payment for
coronary or peripheral angiography, which require contrast agents.
Specifically, the commenter summarized the Act which states that CMS
must create payment groups under the OPPS that ``classify separately
those procedures that utilize contrast agents from those that do not.''
Response: We appreciate the many thoughtful comments related to the
packaged status of IVUS, FFR, and ICE services. We acknowledge that the
costs associated with packaged services may contribute more or less to
the median cost of the independent service, depending on how often the
dependent service is billed with the independent service. It is our
goal to adhere to the principles inherent in a prospective payment
system and to encourage hospitals to utilize resources in a cost-
effective manner. In this case, hospitals must choose whether to
utilize IVUS, FFR, and ICE, balancing the needs of the patient with the
costs associated with the services.
We continue to believe that IVUS, FFR, and ICE are dependent
services that are always provided in association with independent
services. This is different than stating that every angioplasty or
other related independent procedure utilizes IVUS, FFR, or ICE. In
fact, all of the codes about which we received comment are listed as
add-on codes in the CY 2007 CPT book. While we agree that some of these
services may contribute to decisionmaking, we still believe that these
services are never provided without another independent service on the
same day. Therefore, we do not believe it is appropriate to assign
status indicator ``Q'' to CPT codes 93571 and 93572, or any of the
other IVUS, FFR, or ICE services.
While the statute requires us to establish separate APCs for those
services that require contrast and those that do not require contrast,
the statute does not state a similar requirement for the packaged
services that are ancillary and supportive to the main independent
procedure. In this case, IVUS, FFR, and ICE are not the services
themselves that must be mapped to contrast or noncontrast APCs for
payment. Instead, independent services must map to contrast or
noncontrast APCs, as we have done. IVUS, FFR, and ICE are similar to
other supportive packaged services, including drugs and anesthesia.
Packaged codes never map to an APC, and, therefore, it is unnecessary
to distinguish whether they require contrast agents or not. Instead,
the independent procedure must map to a contrast or noncontrast APC.
For the reasons stated above, we are finalizing our proposal to
unconditionally package payment for IVUS, FFR, and ICE services for CY
2008.
Comment: One commenter requested that CMS conditionally package
payment for CPT code 75898 (Angiography through existing catheter for
follow-up study for transcatheter therapy, embolization or infusion),
instead of finalizing the proposal to unconditionally package payment
for this service. The commenter clarified that this is often the only
service performed when a patient has lengthy thrombolytic therapy.
Response: We agree with the commenter that this code should be
conditionally packaged rather than unconditionally packaged, so that
separate payment is made when this service is provided without any
other separately payable services on the same date of service. We are
changing the status indicator for CPT code 75898 to ``Q'' for CY 2008
and including it as an ``STVX-packaged'' code. When provided on the
same date of service as other separately payable services, payment for
CPT code 75898 will be packaged into payment for the other services.
Comment: One commenter requested that CMS continue to pay
separately for CPT codes 67299 (Unlisted procedure, posterior segment)
and 95999 (Unlisted neurological or neuromuscular diagnostic
procedure). These codes describe unlisted procedures, and the commenter
explained that it would be impossible to know whether the services they
describe should be appropriately packaged or separately paid.
Response: We agree with the commenter that CPT codes 67299 and
95999 should not be packaged under the OPPS for CY 2008 because they
are unlisted procedures. Therefore, we are finalizing a separately
payable status indicator and APC assignment for them in Addendum B to
this final rule with comment period.
Comment: Many commenters supported the proposal to package payment
for all intraoperative services and recommended that CMS finalize the
proposal without modification. Several commenters requested that CMS
pay separately for other intraoperative services that it proposed to
package for CY 2008, but did not present unique arguments specific to
any code.
Response: We agree with commenters that packaging payment for
intraoperative services is consistent with the principles of the OPPS
and will help contain costs while creating an incentive for hospitals
to utilize resources in a cost efficient manner. We understand that
hospitals would prefer if certain intraoperative services were paid
separately. In light of the public comments we received, our clinical
advisors reassessed each intraoperative code on the list to ensure that
it was still appropriate for packaged payment. However, we did not see
any compelling reason to pay separately for any of the intraoperative
services that were not already discussed and revised above.
For CY 2008, we are finalizing our CY 2008 proposal, with
modification, to package the payment for all intraoperative HCPCS codes
with three exceptions. Specifically, we are finalizing all of the
packaging changes we proposed, with the exception of conditionally
packaging CPT code 75898 as an ``STVX-packaged'' code and paying
separately for CPT codes 67299 and 95999. Except as otherwise specified
above, we are fully adopting the APC Panel recommendation to package
all intraoperative services and to review the status indicator of CPT
code 96020. Table 10 of this final rule with comment period includes
the final comprehensive list of all codes in the seven categories that
are packaged for CY 2008.
(4) Imaging Supervision and Interpretation Services
We proposed to change the packaging status of many imaging
supervision and interpretation codes for CY 2008. We define ``imaging
supervision and interpretation codes'' as HCPCS codes for services that
are defined as ``radiological supervision and interpretation'' in the
radiology series, 70000 through 79999, of the AMA CY 2007 book of CPT
codes, with the addition of some services in other code ranges of CPT,
Category III CPT tracking codes, or Level II HCPCS codes that are
clinically similar or directly crosswalk to codes defined as
radiological supervision and interpretation services in the CPT
radiology range. We also
[[Page 66631]]
included HCPCS codes that existed in CY 2006 but were deleted and were
replaced in CY 2007. We included the CY 2006 HCPCS codes because we
proposed to use the CY 2006 claims data to calculate the CY 2008 OPPS
median costs on which the CY 2008 payment rates would be based.
In its discussion of ``radiological supervision and
interpretation,'' CPT indicates that ``when a procedure is performed by
two physicians, the radiologic portion of the procedure is designated
as `radiological supervision and interpretation'.'' In addition, CPT
guidance notes that, ``When a physician performs both the procedure and
provides imaging supervision and interpretation, a combination of
procedure codes outside the 70000 series and imaging supervision and
interpretation codes are to be used.'' In the hospital outpatient
setting, the concept of one or more than one physician performing
related procedures does not apply to the reporting of these codes, but
the radiological supervision and interpretation codes clearly are
established for reporting in association with other procedural services
outside the CPT 70000 series. Because these imaging supervision and
interpretation codes are always reported for imaging services that
support the performance of an independent procedure and they are, by
definition, always provided in the same operative session as the
independent procedure, we believe that it is appropriate to package
their payment into the OPPS payment for the independent procedure
performed.
In addition to radiological supervision and interpretation codes in
the radiology range of CPT codes, there are CPT codes in other series
that describe similar procedures that we proposed to include in the
group of imaging supervision and interpretation codes proposed for
packaging under the CY 2008 OPPS. For example, CPT code 93555 (Imaging
supervision, interpretation and report for injection procedure(s)
during cardiac catheterization; ventricular and/or atrial angiography)
whose payment under the OPPS is currently packaged, is commonly
reported with an injection procedure code, such as CPT code 93543
(Injection procedure during cardiac catheterization; for selective left
ventricular or left atrial angiography), whose payment is also
currently packaged under the OPPS, and a cardiac catheterization
procedure code, such as CPT code 93526 (Combined right heart
catheterization and retrograde left heart catheterization), that is
separately paid. In the case of cardiac catheterization, CPT code 93555
describes an imaging supervision and interpretation service in support
of the cardiac catheterization procedure, and this dependent service is
clinically quite similar to radiological supervision and interpretation
codes in the radiology range of CPT. Payment for the cardiac
catheterization imaging supervision and interpretation services has
been packaged since the beginning of the OPPS. Therefore, in developing
the proposal for the CY 2008 proposed rule, we conducted a
comprehensive clinical review of all Category I and Category III CPT
codes and Level II HCPCS codes to identify all codes that describe
imaging supervision and interpretation services. The codes we proposed
to identify as imaging supervision and interpretation codes for CY 2008
that would receive packaged payment were listed in Table 14 of the
proposed rule (72 FR 42665-42667).
Several of these codes, including CPT code 93555 discussed above,
are already unconditionally (that is, always) packaged under the CY
2007 OPPS, where they have been assigned status indicator ``N.''
Payment for these services is made as part of the payment for the
separately payable, independent services with which they are billed. No
separate payment is made for services that we have assigned to status
indicator ``N.'' We did not propose status indicator changes for the
six imaging supervision and interpretation services that were
unconditionally packaged for CY 2007.
We proposed to change the status indicator for 33 imaging
supervision and interpretation services from separately paid to
unconditionally packaged (status indicator ``N'') for the CY 2008 OPPS.
We believed that these services are always integral to and dependent
upon the independent services that they support and, therefore, their
payment would be appropriately packaged because they would generally be
performed on the same date and in the same hospital as the independent
services.
We proposed to change the status indicator for 93 imaging
supervision and interpretation services from separately paid to
conditionally packaged (status indicator ``Q'') as ``special'' packaged
codes for the CY 2008 OPPS. These services may occasionally be provided
at the same time and at the same hospital with one or more other
procedures for which payment is currently packaged under the OPPS, most
commonly injection procedures, and in these cases we would not treat
the imaging supervision and interpretation services as dependent
services for purposes of payment. If we were to unconditionally package
payment for these imaging supervision and interpretation services as
dependent services, hospitals would receive no payment at all for
providing the imaging supervision and interpretation service and the
other minor procedure(s). However, according to our proposal, their
conditional packaging status as ``special'' packaged codes would allow
payment to be provided for these ``Q'' status imaging supervision and
interpretation services as independent services in these limited
circumstances, and for which payment for the accompanying minor
procedure would be packaged. However, when these imaging supervision
and interpretation dependent services are furnished on the same day and
in the same hospital as independent separately paid services,
specifically, any service assigned status indicator ``S,'' ``T,''
``V,'' or ``X,'' we proposed to package payment for them as dependent
services. In all cases, we proposed that hospitals that furnish the
independent services on the same date as the dependent services must
bill them all on the same claim. We believe that when the dependent and
independent services are furnished on the same date and in the same
hospital, they are part of a single complete hospital outpatient
service that is reported with more than one HCPCS code, and no separate
payment should be made for the imaging supervision and interpretation
service that supports the independent service.
In the case of services for which we proposed conditional
packaging, we indicated that we would expect that, although these
services would always be performed in the same session as another
procedure, in some cases that other procedure's payment would also be
packaged. For example, CPT code 73525 (Radiological examination, hip,
arthrography, radiological supervision and interpretation) and CPT code
27093 (Injection procedure for hip arthrography; without anesthesia)
could be provided in a single hospital outpatient encounter and
reported as the only two services on a claim. In the case where only
these two services were performed, the conditionally packaged status of
CPT code 73525 would appropriately allow for its separate payment as an
independent imaging supervision and interpretation arthrography
service, into which payment for the dependent injection procedure would
be packaged.
The estimated overall impact of these changes presented in section
XXII.B. of the proposed rule (section XXIV.B. of this final rule with
comment period) was based on the assumption that
[[Page 66632]]
hospital behavior would not change with regard to when these dependent
services are performed on the same date and by the same hospital that
performs the independent services. To the extent that hospitals could
change their behavior and perform the imaging supervision and
interpretation services more or less frequently, on subsequent dates,
or at settings outside of the hospital, the data would show such a
change in practice in future years and that change would be reflected
in future budget neutrality adjustments. However, with respect to the
imaging supervision and interpretation services in particular, we
believed that hospitals are limited in the extent to which they could
change their behavior with regard to how they furnish these services.
By their definition, these imaging and supervision services generally
must be furnished on the same date and at the same operative location
as the independent procedure in order for the imaging service to
meaningfully contribute to the diagnosis or treatment of the patient.
For those radiological supervision and interpretation codes in the
radiology range of CPT in particular, if the same physician is able to
perform both the procedure and the supervision and interpretation as
stated by CPT, we assume that both the dependent and independent
services would be furnished on the same date in the same hospital, and
hospitals should bill them on the same claim with the same date of
service.
As we indicated earlier in this section, in all cases, we are
providing that hospitals that furnish the imaging supervision and
interpretation service on the same date as the independent service must
bill both services on the same claim. We expect to carefully monitor
any changes in billing practices on a service-specific and hospital-
specific basis to determine whether there is reason to request that
QIOs review the quality of care furnished or to request that Program
Safeguard Contractors review the claims against the medical record.
During the September 2007 APC Panel meeting, the APC Panel
recommended that CMS delay packaging the imaging supervision and
interpretation services because of the reductions in payment that would
occur for services that would only be paid separately if they occurred
with other minor procedures that are already packaged. The Panel was
concerned about the proposed reductions in payment for typical
combinations of expensive imaging services. The Panel asked that CMS
develop an alternative model for these services and present it at the
next APC Panel meeting.
We received many public comments on our proposal to package imaging
supervision and interpretation services for CY 2008. A summary of the
public comments and our response follows.
Comment: Many commenters objected to the packaging of imaging
supervision and interpretation services. They asserted that the
proposal would, in many cases, excessively reduce payments because the
proposal packaged the cost of the service into one or more services
that are already packaged or would inappropriately package the cost of
expensive imaging supervision and interpretation services into more
minor services, like visits or minor diagnostic tests. The commenters
believed that this would result in little or no payment being made for
the more expensive services provided in an encounter. Other commenters
suggested that CMS package only the 33 codes for which the associated
surgical service is separately paid but not package the 93 codes
proposed to be conditionally packaged because payments would be
excessively reduced. As an alternative, one commenter suggested that
CMS review claims data for the 93 imaging supervision and
interpretation codes proposed to be assigned status indicator ``Q'' to
identify high volume combinations of services and evaluate the
combinations for creation of composite APCs. For example, the commenter
suggested that CMS could create a composite APC for CPT codes 72265
(Myelography, lumbosacral, radiological supervision and interpretation)
and 72132 (Computed tomography lumbar spine, with contrast material)
that would ensure that the full payment for CPT code 72265 would always
be made when furnished with CPT code 72132. The commenter was concerned
that CMS could ``overpay'' lumbar CT when no myelography was furnished
but could ``underpay'' when myelography is performed without lumbar
computed tomography (CT) but in addition to another minor services such
as an emergency department visit or other radiological service. Like
others, the commenter was concerned that, as proposed, if an expensive
imaging supervision and interpretation service is billed on the same
date as a visit, the visit would be paid and the expensive service
would not be paid.
Some commenters believed that the absence of consideration of how
payment would be made when unrelated services or packaged services were
the only other services on the claim demonstrated that the CMS proposal
was not carefully or sufficiently analyzed prior to being proposed and
should not be made final. The commenters cited several examples of
packaging with minor services or packaged services that they view as
common, which they believe illuminate the problems with packaging
imaging supervision and interpretation services. The commenters
asserted that CMS should ensure that no service is packaged into a
service that is already packaged. Some commenters believed that the
proposed policy would reduce payment for important interventional
imaging services by 25 percent in the aggregate, would cause CMS to use
fewer claims for ratesetting, and would result in access problems for
patients. Some commenters stated that the methodology reduces the
number of records that could be used to value these imaging codes for
separate payment, thereby resulting in costs that would be much lower
than would be the case if the medians were calculated with a higher
number of claims.
The commenters explained that some of the most common scenarios for
the services that are assigned to APC 0280 (Level III Angiography and
Venography) and are proposed for packaging are comparable to cardiac
catheterization (APC 0080 (Diagnostic Cardiac Catheterization)) in
time, equipment, supply, and labor but under the CMS proposal, the
payment made under APC 0280 would be significantly less than the
payment for APC 0080. Therefore, the commenters asked that the proposal
to package services in APCs 0279 (Level II Angiography and Venography),
280, and 668 (Level I Angiography and Venography) not be adopted in CY
2008 because the packaging would result in payments that are much less
than the cost of furnishing the services. One commenter added that it
is methodologically circular and unreasonable to package payment for
services that already include other packaged services.
Response: We have carefully considered the comments of the APC
Panel and the many thoughtful public comments we received on the
proposal to package imaging supervision and interpretation services for
the CY 2008 OPPS. We spent considerable time and effort in analysis of
the data as we developed our proposed rule, and we appreciate the
helpful comments we received on this issue. We have decided to finalize
our proposal to package these services after refining our methodology
for estimating the median cost of conditionally packaged codes assigned
status indicator ``Q'' to address concerns that packaging significant
services into services that either are already packaged
[[Page 66633]]
or are minor services leads to underpayment and concerns that the
proposal reduced the number of claims available for setting APC medians
for these services. We agree that we should not pay for a more minor
service, such as a visit or minor diagnostic procedure, when the
conditionally packaged imaging supervision and interpretation services
require more resources. We have modified the conditionally packaged
status of these services to be specific to surgical procedures and
called them ``T-packaged services.'' The payment for these imaging
supervision and interpretation codes will be packaged into the payment
for services with a status indicator ``T'' when they appear on the same
date as the surgical procedure. When these imaging supervision and
interpretation services appear with other codes that have any other
payable status indicator (``S,'' ''V,'' or ''X'') or with other
services that have a status indicator ``Q'' on the same date, we would
pay one unit of the ``T-packaged'' service with the highest relative
payment weight. We discuss how we split the claims to acquire ``T-
packaged'' single bills that represent all of the resource costs
associated with the conditionally packaged service in greater detail in
section II.A.2. of this final rule with comment period. The ratesetting
methodology specifically includes single bill claims for T-packed
services that represent the costs of multiple services with status
indicator ``Q'' and other packaged services. We believe that this
resolves many of the payment concerns with regard to our proposal to
treat the majority of supervision and interpretation codes as
conditionally packaged codes. These refinements to our methodology
significantly raised the median costs for a number of these services
compared to the proposed rule median costs. Furthermore, the
refinements, especially those creating single bills from multiple minor
claims, allowed us to use many more claims to estimate a median cost
for these conditionally packaged codes and, therefore, to develop an
APC median cost estimate that better reflects the resources consumed by
these services that are commonly performed in combination with one
another.
We believe that our changes have resulted in resolution of many of
the concerns raised by the commenters and the APC Panel. There were a
number of specific examples cited by the commenters to illustrate their
concerns on this issue. We include the commenters' examples below,
expanded to add the CY 2008 final rule payment. In the examples below,
``pkg'' means payment is packaged; ``na'' means not applicable.
Example 1.--Myleography and Lumbosacral CT With Contrast
--------------------------------------------------------------------------------------------------------------------------------------------------------
CY 2007 CY 2008 Proposed CY 2008 CY 2008 Final
HCPCS Code Descriptor APC CY 2007 SI CY 2007 Payment payment APC CY 2008 SI payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
72265................... Contrast X-ray 0274 S............. $157.01......... pkg............. 0274 Q............ $481.46
lower spine.
72132................... CT lumbar spine w/ 0283 S............. $250.94......... $751.09......... 0283 S............ $277.48
dye.
-------------------------------------------------------------------------------------------------------------------------------
Sum................. ................... ......... .............. $407.95......... $751.09......... ......... ............. $758.94
--------------------------------------------------------------------------------------------------------------------------------------------------------
Example 2.--Angiography, Carotid, Cervical, Vertebral and/or Intracranial
--------------------------------------------------------------------------------------------------------------------------------------------------------
CY 2007 CY 2008 Proposed CY 2008 CY 2008 Final
HCPCS Code Descriptor APC CY 2007 SI CY 2007 Payment payment APC CY 2008 SI payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
36216................... Place catheter in ......... N............. pkg............. pkg............. na N............ pkg
artery.
36215................... Place catheter in ......... N............. pkg............. pkg............. na N............ pkg
artery.
36217................... Place catheter in ......... N............. pkg............. pkg............. na N............ pkg
artery.
36216-59................ Place catheter in ......... N............. pkg............. pkg............. na N............ pkg
artery.
75671................... Artery Xrays head 0280 S............. $1,279.92....... pkg............. 0280 Q............ $2,847.85
and neck.
75680................... Artery Xrays, neck. 0280 S............. $1,279.92....... pkg............. 0279 Q............ pkg
75685X2................. Artery Xrays, spine 0280 S............. $2,559.84....... $1,442.28....... 0279 Q............ pkg
-------------------------------------------------------------------------------------------------------------------------------
Sum................. ................... ......... .............. $5,119.68....... $1,442.28....... ......... ............. $2,847.85
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Several commenters submitted this example or this example with minor variation. The final payment for this service in its entirety is similar to
the payment for cardiac catheterization (APC 0080), to which the commenters compared this service.
Example 3.--Evaluation and Percutaneous Revascularization of Graft
--------------------------------------------------------------------------------------------------------------------------------------------------------
CY 2007 CY 2008 Proposed CY 2008 CY 2008 Final
HCPCS Code Descriptor APC CY 2007 SI CY 2007 Payment payment APC CY 2008 SI payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
36145X2................. Place catheter in na N............. pkg............. pkg............. na N............ pkg
artery.
75790................... Visualize A-V shunt 0279 S............. $584.32......... pkg............. 0668 Q............ pkg
G0393................... A-V fistula or 0081 T............. $2,639.19....... $2,934.24....... 0083 T............ $2,890.72
graft venous.
75978X2................. Repair venous 0668 S............. $767.90......... pkg............. 0083 Q............ pkg
blockage.
35476................... Repair venous 0081 T............. $1,319.60....... $1,467.37....... 0083 T............ $1,445.36
blockage.
-------------------------------------------------------------------------------------------------------------------------------
Sum................. ................... ......... .............. $5,311.01....... $4,401.61....... ......... ............. $4,336.08
--------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 66634]]
Example 4.--Diagnostic Angiography With Balloon Angioplasty of Superficial Femoral Artery
--------------------------------------------------------------------------------------------------------------------------------------------------------
CY 2007 CY 2008 Proposed CY 2008 CY 2008 Final
HCPCS Code Descriptor APC CY 2007 SI CY 2007 Payment payment APC CY 2008 SI payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
75625................... Contrast Xray exam 0280 S............. $1,279.92....... pkg............. 0279 Q............ pkg
of aorta.
75716................... Artery Xrays, arms/ 0280 S............. $1,279.92....... pkg............. 0279 Q............ pkg
legs.
75774................... Artery Xray, each 0279 S............. $584.32......... pkg............. na N............ pkg
vessel.
75774................... Artery Xray, each 0279 S............. $584.32......... pkg............. na N............ pkg
vessel.
36247................... Place catheter in ......... N............. pkg............. pkg............. na N............ pkg
artery.
35474................... Repair arterial 0081 T............. $2,639.19....... $2,934.24....... 0083 T............ $2,890.72
blockage.
35474................... Repair arterial 0081 T............. $1,319.60....... $1,467.37....... 0083 T............ $1,445.36
blockage.
75962................... Repair atrial 0668 S............. $383.95......... pkg............. 0083 Q............ pkg
blockage.
75964................... Repair artery 0668 S............. $383.95......... pkg............. na N............ pkg
blockage, each.
-------------------------------------------------------------------------------------------------------------------------------
Sum................. ................... ......... .............. $8,455.17....... $4,401.61....... ......... ............. $4336.08
--------------------------------------------------------------------------------------------------------------------------------------------------------
Comment: Some commenters believed that CMS should not package
imaging supervision and interpretation services because CMS did not
conduct a sufficiently thorough analysis of the many ways that CPT
codes can be reported for services where there could be more than one
surgical CPT code associated with a single imaging supervision and
interpretation service. The commenters stated that these codes are
created on a ``component'' basis to deal effectively with the huge
variation in the combinations of services that could occur.
Response: We disagree with the commenters. We acknowledge that the
APC Panel and the commenters raised concerns about the packaging of
these services that we did not fully anticipate in development of the
proposed rule. However, the purpose of the APC Panel and the exposure
of the proposal to public comment are to raise issues for our
consideration as we develop final policies for the final rule. We
appreciate the assistance of the APC Panel and the many thoughtful
public comments we received on the proposal to package these codes. We
recognize that the codes are created as they exist, in order to
describe many different treatment scenarios through the use of multiple
and varied combinations of codes. As we discuss above, we have
developed a methodology that addresses the concerns raised by the
commenters and, as such, continue to believe that it is appropriate to
package these services for CY 2008.
Comment: Some commenters believed that the revenue code to CCR
mapping for these services is problematic because most are billed with
revenue code 0361 and revenue code 0361 is mapped to the surgery cost
center. However, as the commenters pointed out, most of these
procedures are performed in the imaging department or the heart
catheterization laboratory and, therefore, their median cost
calculation is highly suspect.
Response: We do not view the unknown amount of error that occurs as
a result of a theoretical conflict between the revenue code reported
for a service and the CCR used to reduce that charge to an estimated
cost as justification to not package these services. The costs we
calculate for purposes of establishing median costs for ratesetting are
estimated costs and as such, in general, there is error in them to the
extent that the charges are reported under a revenue code that maps to
a cost center in which the costs for the services are not found.
Hospitals select the revenue codes with which they report services to
Medicare and other payers for a wide range of reasons over which CMS
generally exercises no control. The CMS crosswalk of revenue codes to
cost centers is available for inspection and comment at the CMS Web
site at: http://www.cms.hhs.gov/HospitalOutpatientPPS/. Hospitals that
want to ensure that the correct CCR is applied to a service could, if
they chose, use this crosswalk to select either the revenue codes to
report or the cost center to use for costs reported with a particular
revenue code.
Comment: Some commenters believed that implementation of the
imaging and supervision packaging would present huge operational
challenges for hospitals to ensure that codes and charges continue to
be billed so that the data in future years will be acceptable as the
basis for setting relative weights for the OPPS. The commenters stated
that hospitals will cease to report the codes and charges for the
services that are no longer separately paid and that the costs of the
services will then be lost to the payment system and the median costs
for the services that should carry the packaging will be
inappropriately low.
Response: The commenters did not articulate how implementation of
the imaging supervision and interpretation packaging proposal would
present huge operational challenges for hospitals to ensure that the
codes and charges continue to be billed so that future claims will
contain the necessary costs for setting relative weights for the OPPS.
Hospitals need only continue to report the codes and charges for all of
the services they furnish. There are no new billing requirements
associated with this change in payment policy. Moreover, hospitals are
required to charge the same amount to all payers for the same services.
We understand that many private payers continue to pay a percent of
charges, creating incentives for hospitals to report and charge for all
services furnished to all patients.
Comment: Some commenters suggested that CMS update the OPPS
packaging policies to address newly added or deleted codes.
Response: We routinely review all new or revised HCPCS codes each
year to determine what status indicator to assign and whether other
changes to our files are needed. We also indicate new codes with a
change indicator in Addendum B to this final rule with comment period,
and we solicit public comments on the interim APC placement and status
indicator we assign to them for those HCPCS codes designated with
comment indicator ``NI'' in the final rule with comment period. We do
not review deleted codes because they naturally fall out of the system,
beginning in the claims for the period in which they are deleted,
although we continue to assign their claims data for ratesetting
purposes.
Comment: Some commenters expressed concerns with the treatment of
the claims data for imaging supervision and interpretation codes with
status indicator ``Q'' with regard to the impact on the number of
multiple procedure claims. Some commenters stated that reporting
packaged services
[[Page 66635]]
will create more multiple procedure bills that will not be used to set
rates.
Response: The reporting of packaged services will not result in
more multiple procedure claims because the packaged service, which has
a status indicator of ``N'' for data purposes, unless it is changed to
be separately paid, will not by itself cause a claim to be viewed as a
multiple major procedure claim. Moreover, if packaged services and
their charges are not reported, the payment for the services into which
their cost is packaged may be understated. Therefore, it is important
that hospitals report all services furnished and the associated
charges.
Comment: Some commenters indicated that where there are multiple
codes with status indicator ``Q'' on a claim and no separately paid
services, they are assigned status indicator ``N'' and sent to multiple
minors because the assignment of the status indicator ``N'' happens
before the split. They suggested that if the assignment happened after
the split and after the ``pseudo'' single creation, they could be used
in the median calculation for the APC.
Response: The commenter correctly describes how codes with status
indicator ``Q'' were treated in this circumstance for the proposed rule
data. We agree that claims with multiple occurrences of codes with
status indicator ``Q'' should be used to estimate the APC median cost
through which they will be separately paid. In response to the public
comments we received, we have revised the data process in several
places to address the estimation of costs for services with a status
indicator of ``Q.'' (See section II.A.2.b. of this final rule with
comment period for further discussion of the changes to the data
process.) With regard to this particular comment, we continue to assign
claims with multiple ``Q'' procedure or packaged services to the
multiple minor file. We then create additional single bills from the
multiple minor file by identifying which conditionally packaged code
will be the prime code that will carry the packaging by selecting the
conditionally packaged code with the highest payment for CY 2007 and
packaging all costs of the other codes into the cost for that code. We
also set the units to one for the prime code to reflect our policy of
only paying one unit of a service for codes with a status indicator of
``Q.'' That claim then becomes a single procedure claim assigned to the
APC to which the prime code is assigned. These modifications have
resulted in the use of many more claims than were used for the proposed
rule to set APC medians where conditionally packaged codes are
assigned.
Comment: One commenter believed that the data for many single bills
for the services with status indicator ``Q'' will be lost because CMS
assesses the status of the status indicator ``Q'' code before applying
the bypass list. The commenters stated that where there are three
services on the claim, two of which are on the bypass list, the status
indicator ``Q'' service will be changed to packaged before the bypass
list is applied and the two bypass codes will leave the claim without
packaging. The commenter added that there will then be no code to which
to package the cost of the status indicator ``Q'' code and the data
will neither be used nor packaged into anything (because nothing is
left for it to be packaged with). The commenter believed that if CMS
had made the assignment of the ``Q'' after the bypass codes were
removed, the data could be used to set the APC median for the ``Q''
service and more claims could have been used.
Response: The commenter accurately described the treatment of a
code with status indicator ``Q'' if it is on the same claim with two
codes that are on the bypass list. However, we disagree with the
commenter's recommendation. First, by definition, codes on the bypass
list do not have significant packaging. We specifically reassessed the
codes included on the bypass list in light of this packaging proposal
to ensure removal of any services with significant packaging. The
circumstances where ``Q'' service data would remain on a claim as
``packaging'' after removing the other two codes as bypass codes should
be very limited. Second, we would not want to use that data to set the
median cost for the ``Q'' status service because the final payment
disposition of the code with status indicator ``Q'' on the claim would
be packaged. Under this commenter's recommendation, we would be sending
the data for the status indicator ``Q'' codes to the APC to which it is
assigned even though, when the claim was processed, no separate payment
would be made for the status indicator ``Q'' code.
Comment: One commenter found that its calculation of median costs
using proposed rule data for the imaging supervision and interpretation
services to which CMS proposed to assign status indicator ``Q''
resulted in median costs for these codes and the APCs to which they
were assigned that were significantly higher than the median costs
calculated by CMS for these codes and their APCs. The commenter was
concerned that CMS may have inadvertently failed to include the
packaged costs in the calculation of the medians for these costs codes.
Response: The commenter is correct in that we inadvertently erred
and did not include the packaged costs of ``Q'' status procedures in
the calculation of the medians for these codes and their related APCs
in the proposed rule. We have packaged these costs with the ``Q''
procedures for this final rule with comment period, in addition to
making the other modifications to the calculation of the median costs
for these codes as discussed in detail above and in section II.A.2. of
this final rule with comment period.
For CY 2008, we are finalizing our proposal, with modification as
discussed above, to unconditionally or conditionally packaged imaging
supervision and interpretation services. These codes, with their
assigned status indicator ``N'' as unconditionally packaged or ``Q'' as
``T-packaged'' codes, are listed in Table 10 of this final rule with
comment period. We are not accepting the APC Panel recommendation to
delay packaging of these services and provide an alternative model at
the next Panel meeting, because we are finalizing a modified model. We
will review the final CY 2008 policy, including the ratesetting
methodology, with the APC Panel at its 2008 winter meeting.
(5) Diagnostic Radiopharmaceuticals
For CY 2008, we proposed to change the packaging status of
diagnostic radiopharmaceuticals as part of our overall enhanced
packaging approach for the CY 2008 OPPS. Packaging costs into a single
aggregate payment for a service, encounter, or episode of care is a
fundamental principle that distinguishes a prospective payment system
from a fee schedule. In general, packaging the costs of supportive
items and services into the payment for the independent procedure or
service with which they are associated encourages hospital efficiencies
and also enables hospitals to manage their resources with maximum
flexibility. As we stated in the CY 2007 OPPS/ASC final rule with
comment period, we believe that a policy to package payment for
additional radiopharmaceuticals (other than those already packaged when
their per day costs are below the packaging threshold for OPPS drugs,
biologicals, and radiopharmaceuticals based on data for the update
year) is consistent with OPPS packaging principles and would provide
greater administrative simplicity for hospitals (71 FR 68094).
All nuclear medicine procedures require the use of at least one
radiopharmaceutical, and there are only
[[Page 66636]]
a small number of radiopharmaceuticals that may be appropriately billed
with each diagnostic nuclear medicine procedure. While examining the CY
2005 hospital claims data in preparation for the CY 2007 OPPS/ASC
proposed rule, we identified a significant number of diagnostic nuclear
medicine procedure claims that were missing HCPCS codes for the
associated radiopharmaceutical. At that time, 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, some hospitals may have decided
not to include the specific radiopharmaceutical HCPCS code and an
associated charge on the claim. A second reason could be that the
hospitals may have incorporated the cost of the radiopharmaceutical
into the charges for the associated nuclear medicine procedures. A
third possibility not offered in the CY 2007 OPPS/ASC proposed rule is
that hospitals may have included the charges for radiopharmaceuticals
on an uncoded revenue code line.
In the CY 2007 OPPS/ASC proposed rule, we did not propose packaging
payment for radiopharmaceuticals with per day costs above the $55 CY
2007 packaging threshold because we indicated that we were concerned
that payments for certain nuclear medicine procedures could potentially
be less than the costs of some of the packaged radiopharmaceuticals,
especially those that are relatively expensive. At the same time, we
also noted the GAO's comment in reference to the CY 2006 OPPS proposed
rule that stated 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 because there may be more than
one radiopharmaceutical that may be used for a particular procedure. We
also expressed concern that packaging payment for additional
radiopharmaceuticals could provoke treatment decisions that may not
reflect use of the most clinically appropriate radiopharmaceutical for
a particular nuclear medicine procedure in any specific case (71 FR
68094).
After considering this issue further and examining our CY 2006
claims data for the CY 2008 OPPS update, as we indicated in the CY 2008
OPPS/ASC proposed rule, we believe that it is most appropriate to
package payment for some radiopharmaceuticals, specifically diagnostic
radiopharmaceuticals, into the payment for diagnostic nuclear medicine
procedures for CY 2008. We expect that packaging would encourage
hospitals to use the most cost efficient diagnostic radiopharmaceutical
products that are clinically appropriate. We anticipate that hospitals
would continue to provide care that is aligned with the best interests
of the patient. Furthermore, we believe that it would be the intent of
most hospitals to provide both the diagnostic radiopharmaceutical and
the associated diagnostic nuclear medicine procedure at the time the
diagnostic radiopharmaceutical is administered and not to send patients
to a different provider for administration of the radiopharmaceutical.
As we indicated in the proposed rule, we do not believe that our
packaging proposal would limit beneficiaries' ability to receive
clinically appropriate diagnostic procedures. Again, the OPPS is a
system of averages, and payment in the aggregate is intended to be
adequate, although payment for any one service may be higher or lower
than a hospital's actual costs in that case.
For CY 2008, we have separated radiopharmaceuticals into two
groupings. The first group includes diagnostic radiopharmaceuticals,
while the second group includes therapeutic radiopharmaceuticals. We
identified all diagnostic radiopharmaceuticals as those Level II HCPCS
codes that include the term ``diagnostic'' along with a
radiopharmaceutical in their long code descriptors. Therefore, we were
able to distinguish therapeutic radiopharmaceuticals from diagnostic
radiopharmaceuticals as those Level II HCPCS codes that have the term
``therapeutic'' along with a radiopharmaceutical in their long code
descriptors. There currently are no HCPCS C-codes used to report
radiopharmaceuticals under the OPPS. For CY 2008, we proposed to
package payment for all diagnostic radiopharmaceuticals that are not
otherwise packaged according to the CY 2008 packaging threshold for
drugs, biologicals, and radiopharmaceuticals that we proposed. We
proposed this packaging approach for diagnostic radiopharmaceuticals,
while we proposed to continue to pay separately for therapeutic
radiopharmaceuticals with an average per day cost of more than $60 as
discussed in section V.B.3.a.(c) of this final rule with comment
period. In that section, we review our reasons for treating diagnostic
radiopharmaceuticals (as well as contrast media) differently from other
types of specified covered outpatient drugs identified in section
1833(t)(B) of the Act.
Diagnostic radiopharmaceuticals are always intended to be used with
a diagnostic nuclear medicine procedure. In examining our CY 2006
claims data, we were able to match most diagnostic radiopharmaceuticals
to their associated diagnostic procedures and most diagnostic nuclear
medicine procedures to their associated diagnostic radiopharmaceuticals
in the vast majority of single bills used for ratesetting. We estimate
that less than 5 percent of all claims with a diagnostic
radiopharmaceutical had no corresponding diagnostic nuclear medicine
procedure. In addition, we found that only about 13 percent of all
single bills with a diagnostic nuclear medicine procedure code had no
corresponding diagnostic radiopharmaceutical billed. These statistics
indicate that, in a majority of our single bills for diagnostic nuclear
medicine procedures, a diagnostic radiopharmaceutical HCPCS code is
included on the single bill. Table 15 in the proposed rule (72 FR
42668) presented the top 20 diagnostic nuclear medicine procedures in
terms of the overall frequency with which they are reported in the OPPS
claims data. Among these high volume diagnostic nuclear medicine
procedures, their single bills included a HCPCS code for a diagnostic
radiopharmaceutical at least 84 percent of the time for 19 of the top
20 procedures. More specifically, 84 to 86 percent of the single bills
for 4 diagnostic nuclear medicine procedures included a diagnostic
radiopharmaceutical, 87 to 89 percent of the single bills for 8
diagnostic nuclear medicine procedures included a diagnostic
radiopharmaceutical, and 90 percent or more of the single bills for 7
diagnostic nuclear medicine procedures included a diagnostic
radiopharmaceutical.
Among the lower volume diagnostic nuclear medicine procedures
(which were outside the top 20 in terms of volume), there was still
good representation of diagnostic radiopharmaceutical HCPCS codes on
the single bills for most procedures. About 40 percent of the low
volume diagnostic nuclear medicine procedures had at least 80 percent
of the single bills for that diagnostic procedure that included a
diagnostic radiopharmaceutical HCPCS code; about 37 percent of the low
volume diagnostic procedures had between 50 to 79 percent of the single
bills that included a diagnostic radiopharmaceutical HCPCS code; and
about 23 percent of the low volume diagnostic procedures
[[Page 66637]]
had less than 50 percent of the single bills that include a diagnostic
radiopharmaceutical HCPCS code. For the few diagnostic nuclear medicine
procedures where less than 50 percent of the single bills included a
diagnostic radiopharmaceutical HCPCS code, we believed there could be
several reasons why the percentage of single bills for the diagnostic
nuclear medicine procedure with a diagnostic radiopharmaceutical HCPCS
code was low.
As noted earlier, it is possible that hospitals may have included
the charge for the radiopharmaceutical in the charge for the diagnostic
nuclear medicine procedure itself or on an uncoded revenue code line
instead of reporting charges for a specific diagnostic
radiopharmaceutical HCPCS code. We found that 24 percent of all single
bills for a diagnostic nuclear medicine procedure but without a coded
diagnostic radiopharmaceutical had uncoded costs in a revenue code that
might contain diagnostic radiopharmaceutical costs, specifically,
revenue codes 0254 (Drugs Incident to Other Diagnostic Services), 0255
(Drugs Incident to Radiology), 0343 (Diagnostic Radiopharmaceuticals),
0621 (Supplies Incident to Radiology), and 0622 (Supplies Incident to
Other Diagnostic Services). In comparison, we found that only 2 percent
of diagnostic nuclear medicine single bills with a nuclear medicine
procedure and a coded diagnostic radiopharmaceutical had uncoded costs
in these revenue codes. It is also possible that some of these
procedures typically used a diagnostic radiopharmaceutical subject to
packaged payment under the CY 2006 OPPS, and hospitals may have chosen
not to report a separate charge for the diagnostic radiopharmaceutical.
Payment for diagnostic radiopharmaceuticals commonly used with some
diagnostic nuclear medicine procedures would already be packaged
because these diagnostic radiopharmaceuticals' average per day costs
were less than $50 in CY 2006. We stated in the proposed rule that the
CY 2008 proposal to package additional diagnostic radiopharmaceuticals
would have little impact on the payment for those diagnostic procedures
that typically use inexpensive diagnostic radiopharmaceuticals that
would be packaged under our proposed CY 2008 packaging threshold of
$60, except to the extent that the budget neutrality adjustment due to
the broader packaging proposal leads to an increase in the scaler and
an increase in the payment for procedures in general.
At its March 2007 meeting, the APC Panel recommended that CMS work
with stakeholders on issues related to payment for
radiopharmaceuticals, including evaluating claims data for different
classes of radiopharmaceuticals and ensuring that a nuclear medicine
procedure claim always includes at least one reported
radiopharmaceutical agent. In the proposed rule, we noted that we
planned to accept the APC Panel's recommendation, and we specifically
welcomed public comment on the hospitals' burden involved should we
require such precise reporting. We also sought public comment on the
importance of such a requirement in light of our above discussion on
the representation of diagnostic radiopharmaceuticals in the single
bills for diagnostic nuclear medicine procedures, the presence of
uncoded revenue code charges specific to diagnostic
radiopharmaceuticals on claims without a coded diagnostic
radiopharmaceutical, and our proposal to package payment for all
diagnostic radiopharmaceuticals.
As we indicated in the proposed rule, we are aware that several
diagnostic radiopharmaceuticals may be used for multiple day studies;
that is, a particular diagnostic radiopharmaceutical may be
administered on one day and a related diagnostic nuclear medicine
procedure may be performed on a subsequent day. While we understand
that multiple day episodes for diagnostic radiopharmaceuticals and the
related diagnostic nuclear medicine procedures occur, we expect that
this would be a small proportion of all diagnostic nuclear medicine
imaging procedures. We estimate that, roughly, 15 diagnostic
radiopharmaceuticals have a half-life longer than one day such that
they could support diagnostic nuclear medicine scans on different days.
We believe these diagnostic radiopharmaceuticals would be concentrated
in a specific set of diagnostic procedures. Excluding the 5 percent of
diagnostic radiopharmaceutical claims with no matching diagnostic
nuclear medicine scan for the same beneficiary, we found that a
diagnostic nuclear medicine scan was reported on the same day as a
coded diagnostic radiopharmaceutical 90 percent or more of the time for
10 of these 15 diagnostic radiopharmaceuticals. Further, between 80 and
90 percent single bills for each of the remaining 5 diagnostic
radiopharmaceuticals had a diagnostic nuclear medicine scan on the same
day. In the ``natural'' single bills we use for ratesetting, we package
payment across dates of service. In light of such high percentages of
extended half-life diagnostic radiopharmaceuticals with same day
diagnostic nuclear medicine scans and the ability of ``natural''
singles to package costs across days, we indicated in the proposed rule
that we believe that our standard OPPS ratesetting methodology of using
median costs calculated from claims data would adequately capture the
costs of diagnostic radiopharmaceuticals associated with diagnostic
nuclear medicine procedures that are not provided on the same date of
service.
The packaging proposal we presented would have reduced the overall
frequency of single bills for diagnostic nuclear medicine procedures,
but the percent of single bills out of total claims remained robust for
the majority of diagnostic nuclear medicine procedures. Typically,
packaging more procedures should improve the number of single bill
claims from which to derive median cost estimates because packaging
reduces the number of separately paid procedures on a claim, thereby
creating more single procedure bills. In the case of diagnostic nuclear
medicine procedures, packaging diagnostic radiopharmaceuticals reduced
the overall number of single bills available to calculate median costs
by increasing packaged costs that previously were ignored in the bypass
process. In prior years, we did not consider the costs of
radiopharmaceuticals when we used our bypass methodology to extract
``pseudo'' single claims because we assumed that the cost of
radiopharmaceutical overhead and handling would be included in the
line-item charge for the radiopharmaceutical, and the diagnostic
radiopharmaceuticals were subject to potential separate payment if
their mean per day cost fell above the packaging threshold. The bypass
process sets empirical and clinical criteria for minimal packaging for
a specific list of procedures and services in order to assign packaged
costs to other procedures on a claim and is discussed at length in
section II.A.1. of the proposed rule, and this final rule with comment
period. Generally, we found that changing the status of diagnostic
radiopharmaceuticals to packaged increased the packaging on each claim.
This would make it both harder for nuclear medicine procedures to
qualify for the bypass list and more difficult to assign packaging to
individual diagnostic nuclear medicine procedures, resulting in a
possible reduction of the number of ``pseudo'' singles that are
produced by the bypass process. Notwithstanding this potentiality,
diagnostic nuclear medicine procedures
[[Page 66638]]
continued to have good representation in the single bills. On average,
single bills as a percent of total occurrences remained substantial at
55 percent for individual procedures. We discuss our process for
ratesetting, including the construction and use of single and multiple
bills, in greater detail in section II.A.1. of this final rule with
comment period.
We indicated in the proposed rule that we believe our CY 2006
claims data supported our CY 2008 proposal to package payment for all
diagnostic radiopharmaceuticals and would lead to payment rates for
diagnostic nuclear medicine procedures that appropriately reflect
payment for the costs of the diagnostic radiopharmaceuticals that are
administered to carry out those diagnostic nuclear medicine procedures.
Among the top 20 high volume diagnostic nuclear medicine procedures, at
least 84 percent of the single bills for almost every diagnostic
nuclear medicine procedure included a diagnostic radiopharmaceutical
HCPCS code. While a diagnostic radiopharmaceutical, by definition,
would be anticipated to accompany 100 percent of the diagnostic nuclear
medicine procedures, it is not unexpected that, while percentages in
our claims data are high, they are less than 100 percent. As noted
previously, we have heard anecdotal reports that some hospitals may
include the charges for diagnostic radiopharmaceuticals in their charge
for the diagnostic nuclear medicine procedure or on an uncoded revenue
code line, rather than reporting a HCPCS code for the diagnostic
radiopharmaceutical. Thus, it is likely that the frequency of
diagnostic radiopharmaceutical costs reflected in our claims data were
even higher than the percentages indicated. Furthermore, we note that
the OPPS ratesetting methodology is based on medians, which are less
sensitive to extremes than means and typically do not reflect subtle
changes in cost distributions. Therefore, to the extent that the vast
majority of single bills for a particular diagnostic nuclear medicine
procedure included a diagnostic radiopharmaceutical HCPCS code, the
fact that the percentage was somewhat less than 100 percent was likely
to have minimal impact on the median cost of the procedure in most
cases. Even in those few instances where we had a low total number of
single bills, largely because of low overall volume, we had ample
representation of diagnostic radiopharmaceutical HCPCS codes on the
single bills for the majority of lower volume nuclear medicine
procedures. We also continued to have reasonable representation of
single bills out of total claims in general. Finally, as noted
previously, to the extent that the diagnostic radiopharmaceuticals
commonly used with a particular diagnostic nuclear medicine procedure
were already packaged, the proposal to package additional diagnostic
radiopharmaceuticals would have had little impact on the payment for
these procedures.
The estimated overall impact of these changes presented in section
XXII.B. of the proposed rule (section XXIV.B. of this final rule with
comment period) was based on the assumption that hospital behavior
would not change with regard to whether the dependent diagnostic
radiopharmaceuticals services are provided by the same hospital that
performs the independent services. In order to provide diagnostic
nuclear medicine procedures under this policy, hospitals would either
need to administer the necessary diagnostic radiopharmaceuticals
themselves or refer patients elsewhere for the administration of the
diagnostic radiopharmaceuticals. In the latter case, claims data would
show such a change in practice in future years and that change would be
reflected in future ratesetting. However, with respect to diagnostic
radiopharmaceuticals, we believe that hospitals are limited in the
extent to which they could change their behavior with regard to how
they furnish these items because diagnostic radiopharmaceuticals are
typically provided on the same day as a diagnostic nuclear medicine
procedure. It would be difficult for Hospital A to send patients to
receive diagnostic radiopharmaceuticals from Hospital B and then have
the patients return to Hospital A for the diagnostic nuclear medicine
procedure in the appropriate timeframe (given the radiopharmaceutical's
half-life) to perform a high quality study. We expect that hospitals
would always bill the diagnostic radiopharmaceutical on the same claim
as the other independent services for which the radiopharmaceutical was
administered.
The APC Panel recommended that CMS package radiopharmaceuticals
with a median per day cost of less than $200 but pay separately for
radiopharmaceuticals with a per day cost of $200 or more. The APC Panel
also recommended that CMS should identify nuclear medicine procedure
claims with and without radiopharmaceuticals and should present its
findings to the Panel at the next meeting for consideration of whether
an edit is needed to ensure that the cost of the radiopharmaceutical is
packaged into the payment for the nuclear medicine service.
We received many public comments on our proposal to package payment
for diagnostic radiopharmaceuticals for CY 2008. A summary of the
public comments and our responses follow.
Comment: Some commenters recommended that CMS package
radiopharmaceuticals with a per day cost less than $200 but pay
separately for radiopharmaceuticals with a per day cost of $200 or
more. Other commenters objected to packaging diagnostic
radiopharmaceuticals and asked that CMS continue to pay separately for
radiopharmaceuticals with per day costs that exceed the packaging
threshold for drugs. These commenters explained that FDA views
radiopharmaceuticals to be drugs, they are defined as drugs for
purposes of pass-through payment under OPPS in sections
1833(t)(6)(A)(iii) of the Act, and for purposes of payment as specified
covered outpatient drugs (SCODs) and biologicals in section
1833(t)(14)(B)(i)(l) of the Act. The commenters argued that CMS should,
therefore, pay separately for radiopharmaceuticals with a per day cost
in excess of $60, as it does for other drugs.
The commenters believed that section 1833(t)(14)(B)(i)(l) of the
Act requires CMS to treat radiopharmaceuticals no differently from
other SCODs and, therefore, CMS must pay radiopharmaceuticals actual
acquisition costs or, failing that, charges adjusted to costs. Some
commenters believed that there is no authority for CMS to package drugs
that are incidental or ancillary to a procedure and that by doing so,
CMS is relying on a form of ``functional equivalence'' which is
expressly limited by statute under section 1833(t)(6)(F) of the Act.
The commenters argued that the proposal will create an incentive for
hospitals to not use advanced technologies and will harm patient care.
Some commenters believed that packaging diagnostic radiopharmaceuticals
could discourage hospitals from using the most appropriate drug for
each patient and encourage them to use less clinically effective
radiopharmaceuticals when there is a choice of radiopharmaceutical.
Some commenters added that the proposal ignores medical indications and
focuses solely on cost reduction, which could result in constraints on
medical decisionmaking and would compromise medical care.
Response: After review of the public comments we received on this
issue, we have decided to finalize our proposal to package payment for
diagnostic
[[Page 66639]]
radiopharmaceuticals into the payment for the nuclear medicine services
which cannot be performed without the administration of a
radiopharmaceutical. We refer readers to section V.B.4.b. of this final
rule with comment period for a discussion of the rationale to package
payment for diagnostic radiopharmaceuticals as SCODs and our belief
that the packaged payment provides payment at average acquisition cost
for the products.
We find the argument that we are creating functional equivalence by
packaging the payment for diagnostic radiopharmaceuticals into the
payment for the nuclear medicine services without which they cannot be
performed to be unconvincing. We are not establishing an equivalent
payment for different products based on their function. We are instead
packaging the cost of radiopharmaceuticals, however differential those
costs may be, into the payment for nuclear medicine services to create
an appropriate payment for the nuclear medicine services that use these
products, whether there is one product or multiple products that could
be used to furnish the service. This is analogous to our longstanding
practice of packaging of medical devices into the payment for the
procedure in which they are used, notwithstanding that there may be
different devices that could be used to furnish the service.
Moreover, we do not agree with the argument that paying for
radiopharmaceuticals as part of the payment for the nuclear medicine
service to which they are essential will harm patient care. We believe
that providing packaged payment for radiopharmaceuticals as part of the
nuclear medicine service will cause hospitals and their physician
partners to give even more careful consideration to the selection of
the radiopharmaceutical that is the most appropriate for the patient
whom they are treating.
We are not accepting the APC Panel recommendation to pay separately
for radiopharmaceuticals with a per day cost in excess of $200 because
we could not determine an empirical basis for paying separately for
radiopharmaceuticals with a per day cost in excess of $200.
Comment: Many commenters stated that a diagnostic
radiopharmaceutical is always needed to provide a nuclear medicine
service and, therefore, CMS should use only claims in which both
services were present to compute the median cost for the nuclear
medicine procedure if CMS decides to package diagnostic
radiopharmaceuticals. Some commenters suggested that CMS establish OCE
edits that would require a charge be reported under the diagnostic
radiopharmaceutical revenue code 0343 when there was a charge in
revenue codes 0340 or 0341 for a nuclear medicine procedure. Other
commenters recommended that CMS establish OCE edits that would require
a HCPCS code for a diagnostic radiopharmaceutical be reported on a
claim for a diagnostic nuclear medicine procedure. Some commenters were
concerned that the actual cost of radiopharmaceuticals would be lost
because hospitals would not report the charges on the claim unless CMS
mandates and enforces their reporting.
Response: We agree that it is important that the costs of
radiopharmaceuticals be reported on the same claim with the nuclear
medicine service so that we can have confidence that the payment for
the nuclear medicine procedure reflects the cost of the
radiopharmaceutical as well as the nuclear medicine service. Therefore,
we have used only claims that contain a HCPCS code and charge for a
diagnostic radiopharmaceutical to calculate the median costs of the
nuclear medicine procedures for CY 2008. Moreover, effective for
services furnished on and after January 1, 2008, the OCE will return
for correction any claim for a nuclear medicine procedure that does not
contain a HCPCS code and charge for a diagnostic radiopharmaceutical.
These edits are similar to the edits we have had in place in the OCE
since CY 2005 for medical devices. The significant difference, however,
is that we recognize that, for some nuclear medicine procedures, there
is a choice of radiopharmaceuticals that could be used and, therefore,
the edits will not specify which radiopharmaceutical must be billed
with any given nuclear medicine procedure. We also recognize that, in
some cases, the radiopharmaceutical is administered several days before
the nuclear medicine service is furnished. In these cases, the hospital
will need to hold the claim until after the service is furnished so
that the radiopharmaceutical can appear on the bill with the nuclear
medicine procedure or the bill for the procedure will be returned for
correction. We did not accept the comment that we should establish the
edits using combinations of revenue codes because to do so would not
provide specific information on the particular radiopharmaceutical
being furnished and we could not be certain that the charges were for
radiopharmaceuticals.
Comment: Some commenters asserted that, based on survey data they
gathered, claims data fail to capture hospital average acquisition
costs for radiopharmaceuticals. The commenters, therefore, concluded
that the costs of low volume, high cost radiopharmaceuticals are not
captured in the claims data that is used to set the median costs on
which the nuclear medicine services payment rates are based and the
packaged payment for radiopharmaceuticals will be inadequate to pay for
the cost of the drug. The commenters believed that these incorrectly
priced products are unlikely to continue to be manufactured and thus
will cease to be available. The commenters also stated that it is
unlikely that the industry will develop new products for the market if
they find that hospitals will not use them because of inadequate
payment. The commenters believed that beneficiary care would suffer as
hospitals ceased to furnish the service because payment would be
inadequate to cover the cost. Some commenters explained that, while CMS
implemented revenue codes for diagnostic and therapeutic
radiopharmaceuticals in CY 2004, hospitals have not yet fully reflected
these revenue codes in their billing practices and, therefore, the
claims data are not correct or reliable and CMS should continue to pay
separately for radiopharmaceuticals at charges adjusted to cost. Other
commenters believed that the proposed changes would overestimate
payments for some diagnostic radiopharmaceuticals, underestimate
others, and create improper financial incentives for hospitals and
physicians to select certain radiopharmaceuticals rather than others,
potentially reducing the quality of care.
Response: We believe that we have appropriately calculated the
radiopharmaceutical costs that we are packaging into the nuclear
medicine services by using only claims for nuclear medicine services
that contain a radiopharmaceutical, as noted above. This is analogous
to our process for ensuring that the costs of devices are packaged into
the payment for the APC in which they are used, and we believe that
using only these claims will negate any existing problems with the use
or lack of use of the radiopharmaceutical revenue codes.
With regard to the concern that packaging radiopharmaceuticals will
result in overpayment in some cases and underpayment in others, we note
that the most fundamental characteristic of a prospective payment
system is that payment is to be set at an average for the service,
which, by definition, means that some services are paid more or less
than the average. However, the average
[[Page 66640]]
should provide adequate payment for the service, while creating
incentives for hospitals to control costs and utilization of high cost
services where it is appropriate to do so. We do not believe that
either beneficiary access to care or the quality of care will be
adversely affected because we pay for diagnostic radiopharmaceuticals
as part of the payment for the procedure to which they are an integral
part. With regard to the influence this may have on the development and
production of radiopharmaceuticals, there are many aspects of the
health care economy that influence what is developed and produced, of
which Medicare payment under the OPPS is merely one.
Comment: Some commenters stated that CMS has not provided adequate
information for specialty societies and others to adequately review the
matching of the drugs with the services to determine whether an
appropriate radiopharmaceutical is packaged into the nuclear medicine
services. The commenters indicated that CMS should provide data on the
percent of nuclear medicine claims that were reported with and without
a corresponding radiopharmaceutical so that the public can determine
whether an edit is indicated for reporting these services either
through OCE or backend rate setting and, if so, what edit would be
appropriate.
Response: We provided considerable information and data in support
of our proposal. Moreover, we make available our claims data both for
the proposed rule and the final rule so that the public can perform any
analysis they choose. There are limits to our ability to provide
specialized studies of interest. Therefore, we provide a narrative
claims accounting that is intended to illuminate our data process for
those who would like to use the claims data to explore alternatives.
Comment: Some commenters believed that packaging diagnostic
radiopharmaceuticals would undermine the clinical and resource
homogeneity of the nuclear medicine APCs, especially the cardiac
imaging APCs, resulting in 2 times violations. The commenters stated
that the APC revision that is proposed as a result of the proposed
packaging results in a lack of resource and clinical homogeneity within
the APCs. Specifically, the commenters believed that, by packaging
diagnostic radiopharmaceuticals, CMS created a 2 times violation in APC
0408 because the median costs for the services assigned to the APC vary
widely for the procedure code based on the radiopharmaceutical used.
Response: We agree that packaging costs into the median for a
service to which they are an integral part can change the median cost
for that service and result in 2 times violations. As we noted in the
proposed rule, there were a significant number of APC reassignments to
eliminate 2 times violations that would otherwise have resulted from
the proposed packaging approach. However, we disagree that we should
refrain from packaging payment for necessary items into the payment for
the service in which they are required in order to prevent 2 times
violations from occurring. Instead, we believe that we should make the
necessary reassignments to different APCs where necessary to resolve 2
times violations where they occur. For example, to resolve 2 times
violations that would otherwise have occurred when we used only those
claims for nuclear medicine procedures reporting HCPCS code for
diagnostic radiopharmaceuticals, we made the following APC
reassignments for this final rule with comment period. We reassigned
CPT code 78730 (Urinary bladder residual study (List separately in
addition to code for primary procedure)) from APC 0340 (Minor Ancillary
Procedures) to APC 0389 (Level I Non-Imaging Nuclear Medicine). We
reassigned CPT code 78725 (Kidney function study, non-imaging
radioisotopic study) from APC 0389 to APC 0392 (Level II Non-Imaging
Nuclear Medicine). We reassigned CPT code 78006 (Thyroid imaging, with
uptake; single determination) from APC 0390 (Level I Endocrine Imaging)
to APC 0391 (Level II Endocrine Imaging). With regard to APC 0408
(Level III Tumor/Infection Imaging), that APC contained only one code
for the proposed rule, CPT code 78804 (Radiopharmaceutical localization
of tumor or distribution of radiopharmaceutical agent(s); whole body,
requiring two or more days imaging), and it had a proposed median of
approximately $1,010. For this final rule with comment period, APC 0408
contains 3 CPT codes: 78804 (Radiopharmaceutical localization of tumor
or distribution of radiopharmaceutical agent(s); whole body, requiring
two or more days imaging); 78075 (Adrenal Imaging, cortex and/or
medulla); and 78803 (Radiopharmaceutical localization of tumor or
distribution of radiopharmaceutical agent(t); tomographic (SPECT)). For
this final rule with comment period, APC 408 has a median cost of
approximately $969.
Because we have traditionally paid for a service package under the
OPPS as represented by a HCPCS code for the major procedure that is
assigned to an APC group for payment, we assess the applicability of
the 2 times rule to services at the HCPCS code level, not at a more
specific level based on the individual diagnostic radiopharmaceuticals
that may be utilized in a service reported with a single HCPCS code. If
the use of a very expensive diagnostic radiopharmaceutical in a
clinical scenario causes a specific procedure to be much more expensive
for the hospital than the APC payment, we consider such a case to be
the natural consequence of a prospective payment system that
anticipates that some cases will be more costly and other less costly
than the procedure payment. In addition, very high cost cases could be
eligible for outlier payment. As we note elsewhere in this final rule
with comment period, decisions about packaging and bundling payment
involve a balance between ensuring some separate payment for individual
services and establishing incentives for efficiency through larger
units of payment. In the case of diagnostic radiopharmaceuticals, these
products will be part of the OPPS payment package for the procedures in
which they are used beginning in CY 2008.
Comment: One commenter objected to packaging of diagnostic
radiopharmaceuticals because the commenter believed that including the
payment for the item in the payment for the procedure would improperly
subject the portion of the payment that is attributable to the
diagnostic radiopharmaceutical to wage adjustment. The commenter
indicated that there should be no wage adjustment applied to the cost
of a diagnostic radiopharmaceutical.
Response: We disagree that we should not package the payment for a
radiopharmaceutical into the payment for the procedure in which it is
an integral part because part of the procedure payment will be wage
adjusted. Since the inception of the OPPS, we have determined that,
approximately 60 percent of the cost of an OPPS service is attributable
to wage costs. That figure is an overall average percent that takes
into account the extent to which there are costs in the OPPS payments
that are not attributable to wages. We have a longstanding policy of
wage adjusting 60 percent of the cost of the APC, regardless of whether
it is an office visit (which is mostly wage costs) or an ICD
replacement (in which most of the cost is a device), because our
analysis shows that, overall, OPPS
[[Page 66641]]
services approximately 60 percent of the cost is attributable to wages.
Comment: Some commenters stated that diagnostic
radiopharmaceuticals are not interchangeable and carry high costs
because, if the patient for whom the hospital secures a
radiopharmaceutical cannot use the product, the hospital cannot bill
for it and must absorb the loss. The commenters stated that hospitals
have little or no flexibility in determining the diagnostic
radiopharmaceutical that they purchase and have little ability to
achieve efficiency.
Response: We recognize that radiopharmaceuticals are specialized
products that have unique costs associated with them. However, we
believe that the costs should be reflected in the charges that
hospitals set for them and in the cost report where the full costs of
the services are carried. Therefore, the costs will be calculated like
any other OPPS cost and packaged into the total cost of the nuclear
medicine service to which they are an integral part and will be the
basis for the payment rate for the nuclear medicine service in the same
way that other packaged costs contribute to the payment rate for the
services to which they are an integral part.
Comment: Several commenters stated that HCPCS codes A9542 (Indium
IN-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5
millicuires) and A9544 (Iodine I-131 tositumomab, diagnostic, per study
dose) are not diagnostic radiopharmaceuticals and should not be
packaged. The commenters reported that they are not used to diagnose
the patient's disease but instead are used to assess the
biodistribution of radioimmunotherapy agents or to calculate the
therapeutic dose of those agents. The commenters contended that,
although packaging is intended to create incentives for using the most
cost-effective product, in these cases there are no other products that
are available, and hence these products should always be paid
separately. The commenters concluded that the proposed payments for
these services are so low that hospitals will not offer the treatments
to Medicare beneficiaries.
Response: We continue to believe that HCPCS codes A9542 and A9544
are diagnostic radiopharmaceuticals. While they are not used to
diagnose disease, they are used to determine whether future therapeutic
services would be beneficial to the patient and to determine how to
proceed with therapy. This is analogous to the use of positron emission
tomography (PET) scanning for staging purposes when there has already
been a diagnosis of disease but the physician is seeking information to
use in planning a course of therapy. The scan is a diagnostic service,
notwithstanding that the disease has previously been diagnosed and the
diagnostic service is essential to planning therapy. While we recognize
that these radiopharmaceuticals are sole source products, we do not
believe that is sufficient to justify treating them differently from
other diagnostic radiopharmaceuticals. Moreover, given that the
Medicare population is such a dominant portion of the population to
which these services are targeted, we do not believe that hospitals
will cease to provide the service because the payment is packaged into
the payment for the service to which the radiopharmaceutical is an
integral part. We also note that, under 42 CFR 489.53(a)(2), CMS may
terminate the provider agreement of any hospital that furnishes this or
any other service to its patients but fails to also furnish it to
Medicare patients who need it.
Comment: Some commenters asked that CMS pay hospitals separately
for diagnostic radiopharmaceuticals based on acquisition costs. The
commenters had a variety of recommendations regarding how CMS should
acquire acquisition cost data on which CMS could base separate payment
for radiopharmaceuticals. Some commenters recommended that CMS conduct
surveys of radiopharmaceutical costs or rely on the external data from
surveys conducted by outside entities to obtain cost data. Some
commenters recommended that CMS work with stakeholders to develop a
standardized radiopharmaceutical reporting format and base separate
payment for radiopharmaceuticals on a radiopharmaceutical average
selling nuclear pharmacy price (ASNPP), average acquisition cost (ACC),
or another voluntarily reported amount if furnished by manufacturers
and nuclear pharmacies, instead of claims data charges adjusted to cost
by departmental CCRs. Other commenters suggested that CMS require
hospitals to report acquisition costs for radiopharmaceuticals,
instruct contractors to collect periodic reports from hospitals of
diagnostic radiopharmaceutical costs, and gather and summarize nuclear
pharmacy invoice data through CY 2008 that would be used to set CY 2009
rates. The commenters stated that separate payment of diagnostic
radiopharmaceuticals for CY 2008 is critical to enable hospitals to
account for the complex combinations of radiopharmaceuticals used to
provide nuclear medicine procedures. Some commenters indicated that
continuation of the current payment at charges reduced to cost by the
overall CCR, while not ideal, is a reasonable temporary solution until
CMS can implement a long term solution to pay acquisition costs for
radiopharmaceuticals as required by law. Some commenters supported CMS'
use of its claims data alone to set the CY 2008 payment rates, but only
if no external data source is available to pay actual acquisition costs
for radiopharmaceuticals.
Response: As we previously stated, we have decided to package
payment for diagnostic radiopharmaceuticals into the payment for
nuclear medicine services. Therefore, proposals for gathering data on
which separate payment could be based are not relevant. However, we
note that when we proposed to acquire ASP data for radiopharmaceuticals
for purposes of paying separately for them under the CY 2006 OPPS,
commenters were virtually unanimous that the industry could not report
valid sales price data on radiopharmaceuticals.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal to provide packaged payment for
diagnostic radiopharmaceuticals, with modification to calculate the
median costs for the APCs for nuclear medicine studies that require a
diagnostic radiopharmaceutical using only claims on which at least one
diagnostic radiopharmaceutical is present. We will implement edits in
the OCE for services furnished on and after January 1, 2008, that will
return to providers any claim for a nuclear medicine study that does
not also report a HCPCS code and charge for a diagnostic
radiopharmaceutical. We are not accepting the APC Panel's
recommendation to set a packaging threshold for diagnostic
radiopharmaceuticals at a median cost of $200 per day. We are accepting
the APC Panel's recommendation to provide information regarding claims
for diagnostic radiopharmaceuticals reported with nuclear medicine
procedures, and we will discuss that information with the Panel at the
2008 winter meeting. Diagnostic radiopharmaceuticals assigned status
indicator ``N'' that will be unconditionally packaged are listed in
Table 10 of this final rule with comment period.
(6) Contrast Agents
For CY 2008, we proposed to package payment for all contrast media
into their
[[Page 66642]]
associated independent diagnostic and therapeutic procedures as part of
our proposed packaging approach for the CY 2008 OPPS (72 FR 42672
through 42674). As noted in section II.A.4.c. of the proposed rule and
this final rule with comment period, packaging the costs of supportive
items and services into the payment for the independent procedure or
service with which they are associated encourages hospital efficiencies
and also enables hospitals to manage their resources with maximum
flexibility. As stated in the proposed rule (72 FR 42672), we believe
that contrast agents are particularly well suited for packaging because
they are always provided in support of an independent diagnostic or
therapeutic procedure that involves imaging, and thus payment for
contrast agents can be packaged into the payment for the associated
separately payable procedures.
Contrast agents are generally considered to be those substances
introduced into or around a structure that, because of the differential
absorption of x-rays, alteration of magnetic fields, or other effects
of the contrast medium in comparison with surrounding tissues, permit
visualization of the structure through an imaging modality. The use of
certain contrast agents is generally associated with specific imaging
modalities, including x-ray, computed tomography (CT), ultrasound, and
magnetic resonance imaging (MRI), for purposes of diagnostic testing or
treatment. They are most commonly administered through an oral or
intravascular route in association with the performance of the
independent procedures involving imaging that are the basis for their
administration. Even in the absence of this proposal to package payment
for all contrast agents, we indicated that we would propose to package
the majority of HCPCS codes for contrast agents recognized under the
OPPS in CY 2008. We consider contrast agents to be drugs under the
OPPS, and as a result they are packaged if their estimated mean per day
cost is equal to or less than $60 for CY 2008. (For more discussion of
our drug packaging criteria, we refer readers to section V.B.2 of this
final rule with comment period.) Seventy-five percent of contrast
agents HCPCS codes have an estimated mean per day cost equal to or less
than $60 based on our CY 2006 proposed rule claims data.
At the time of the proposed rule, contrast agents were described by
those Level II HCPCS codes in the range from Q9945 through Q9964. There
were currently no HCPCS C-codes or other Level II HCPCS codes outside
the range specified above used to report contrast agents under the
OPPS. As shown in Table 19 of the proposed rule, in CY 2007 we packaged
7 out of 20 of these contrast agent HCPCS codes based on the $55
packaging threshold. For CY 2008, we proposed to package all drugs with
a per day mean cost of $60 or less. For CY 2008, the vast majority of
contrast agents would be packaged under the traditional OPPS packaging
methodology using the $60 packaging threshold, based on the CY 2006
claims data available for the proposed rule. In fact, of the 20
contrast agent HCPCS codes we included in our proposed packaging
approach, 15 would have been proposed to be packaged for CY 2008 under
our drug packaging methodology. These 15 codes represent 94 percent of
all occurrences of contrast agents billed under the OPPS, using
proposed rule data. As stated in the proposed rule (72 FR 42672), we
believe that this shift in the packaging status for several of these
agents between CYs 2007 and 2008 may be because, in CY 2007, a number
of the contrast agents exceeded the $55 threshold by only a small
amount and, based on our latest claims data for CY 2008, a number of
these products have now fallen below the proposed $60 threshold. Given
that the vast majority of contrast agents billed would already be
packaged under the OPPS in CY 2008, we stated in the proposed rule (72
FR 42672) that we believe it would be desirable to package payment for
the remaining contrast agents as it promotes efficiency and results in
a consistent payment policy across products that may be used in many of
the same independent procedures. We also noted in the proposed rule (72
FR 42672) that the significant costs associated with these 15 contrast
agents would already be reflected in the median costs for those
independent procedures and, if we were to pay for the 5 remaining
agents separately, we would be treating these 5 agents differently than
the others. If the 5 agents remained separately payable, there would
effectively be two payments for contrast agents when these 5 agents
were billed--a separate payment and a payment for packaged contrast
agents that was part of the procedure payment. This could potentially
provide a payment incentive to administer certain contrast agents that
might not be the most clinically appropriate or cost effective.
Moreover, as noted previously, contrast agents are always provided with
independent procedures and, under a consistent approach to packaging in
keeping with our enhanced efforts to encourage hospital efficiency and
promote value-based purchasing under the OPPS, their payment would be
appropriately packaged for CY 2008.
The estimated overall impact of these changes presented in section
XXII.B. of the proposed rule (and section XXIV.B. of this final rule
with comment period) was based on the assumption that hospital behavior
would not change with regard to when these contrast agents are provided
by the same hospital that performs the imaging procedure. Under this
policy, in order to provide imaging procedures requiring contrast
agents, hospitals will either need to administer the necessary contrast
agent themselves or refer patients elsewhere for the administration of
the contrast agent. In the latter case, claims data would show such a
change in practice in future years and that change would be reflected
in future ratesetting. However, with respect to contrast agents, we
believe that hospitals are limited in the extent to which they could
change their behavior with regard to how they furnish these services
because contrast agents are typically provided on the same day
immediately prior to an imaging procedure being performed. We expected
that hospitals would always bill the contrast agent on the same claim
as the other independent services for which the contrast agent was
administered.
As we indicated earlier, in all cases we are providing that
hospitals that furnish the supportive contrast agent in association
with independent procedures involving imaging must bill both services
on the same claim so that the cost of the contrast agent can be
appropriately packaged into payment for the significant independent
procedure. As noted in the proposed rule (72 FR 42673), we expect to
carefully monitor any changes in billing practices on a service-
specific and hospital-specific basis to determine whether there is
reason to request that QIOs review the quality of care furnished or to
request that Program Safeguard Contractors review the claims against
the medical record.
During its September 2007 APC Panel meeting, the Panel recommended
that contrast agents be packaged as proposed.
We received many public comments on the proposal to package payment
for all contrast agents. A summary of the public comments and our
responses follow.
Comment: Many commenters supported our proposal to package all
contrast agents, while others requested that we pay separately for all
contrast agents in accordance with the Average
[[Page 66643]]
Sales Price (ASP) payment methodology. Many commenters requested that
we treat contrast agents in the same manner as we treat other drugs
under the OPPS, thereby continuing to apply the proposed $60 threshold
to determine packaging status. One commenter expressed concern with the
accuracy of CMS' cost data, and estimated that if contrast agents were
packaged, hospitals would not receive any payment in addition to the
payment for the procedure without contrast. Several commenters
requested that CMS create edits to ensure that the costs for contrast
agents are only packaged with appropriate procedures, rather than with
any code that may appear on the claim. Other commenters requested that
CMS implement edits to ensure that contrast agents are always billed
with procedures that require contrast agents. Some commenters were
concerned that CMS may not be accounting for the full cost of the
contrast agent, because of the methodology used to determine the
acquisition costs of the agents. One commenter noted that it is
difficult for hospitals operationally to treat contrast agents as
packaged, then separately payable the following year, and then packaged
again. In addition, commenters were concerned that packaged status
would encourage less coding accuracy, which would hinder the
development of accurate future payment rates. One commenter expressed
concern that patient access to more expensive contrast agents, such as
gadolinium-based contrast agents, may be limited, if the proposal to
package all contrast agents were finalized.
Response: We have considered all of the comments on this issue and
have concluded that it is appropriate to package all contrast agents
into payment for the procedure in which they are used. Many contrast
agents are packaged currently under the OPPS and have been packaged
since the inception of the OPPS. We have no reason to believe that the
cost data that we developed for contrast agents are insufficient to
result in an appropriate median cost for the services in which the
contrast agent is used. Moreover, we are not convinced that there are
benefits to making separate payment that would outweigh the incentives
for appropriate utilization and efficiency that are created by
packaging the payment for the contrast agent into the payment for the
service in which it is used.
In addition, we do not believe it is necessary to create edits to
ensure that contrast agents are billed in conjunction with services
that require contrast agents. For example, we believe that the payment
rates for CT with and without contrast are accurate, further bolstering
our perspective that hospitals are correctly billing the charges for
contrast agents for those services that require them. There is
currently a significant cost differential that appears to be
appropriate between CT scans with and without contrast, and we have no
reason to believe that this cost differential is inaccurate. For
example, the CY 2008 median cost for CPT code 72192 (Computer
tomographic angiography, pelvis, without contrast material) is
approximately $190. The CY 2008 median cost for CPT code 72193
(Computer tomographic angiography, pelvis, with contrast material) the
same procedure, with contrast, is approximately $249. The CY 2008
median costs for the services in APC 0332 (Computed Tomography Without
Contrast) range from approximately $164 to $227. The CY 2008 proposed
median costs for the services in APC 0283 (Computed Tomography with
Contrast) range from approximately $247 to $333, significantly higher
than the median costs for the procedures that do not involve contrast
media.
Providers have several ways to report contrast agents, including
uncoded charges on revenue code lines, including the charge for the
contrast agent in the charge for the procedure, or reporting the
appropriate HCPCS code for the contrast agent that was used. Prior to
proposing to package payment for all contrast agents, we note that
there were no concerns or complaints about the payment rates for
imaging studies with and without contrast, when a number of the
commonly used contrast agents were packaged. In addition, if we were to
subset claims for procedures that require a contrast agent to use only
those claims that included a coded contrast agent, we would be able to
use many fewer claims, which would cause our median costs to be less
accurate and representative.
Most of the contrast media would have been packaged in the absence
of this packaging proposal, because 75 percent of all contrast agents
fall below the $60 threshold for CY 2008. However, we are interested to
know whether the public thinks it would be beneficial from a
ratesetting perspective to require hospitals to report contrast media
by including HCPCS codes for contrast on all claims for procedures that
use contrast. We are particularly concerned with unnecessarily
burdening hospitals, and are seeking comments in this final rule with
comment period related to how administratively burdensome this
requirement would be for hospitals.
In response to the commenter who found it difficult operationally
to manage changes in the packaged status of contrast media, we note
that we do not anticipate regular changes to the packaged status of
contrast media, now that we are finalizing our proposal to package
payment for all contrast media.
In response to the commenter's concern about payment for expensive
contrast agents like gadolinium-based contrast media, we note that the
gadolinium-based contrast agents would be packaged under the $60
packaging threshold, regardless of whether this proposal to package
payment for all contrast media was finalized. Packaging payment for
these products provides hospitals with an incentive to choose the most
cost-effective contrast agent that meets the needs of the patient.
Comment: Several commenters questioned whether we have the
authority under the Social Security Act to package all contrast agents.
Response: See section V.B.4.b. of this final rule with comment
period for a discussion of the rationale to package payment for
contrast agents as SCODs and our belief that the packaged payment
provides payment at average acquisition cost for the products.
Comment: Several commenters requested that contrast agents used for
echocardiography imaging procedures remain separately paid in CY 2008.
These commenters were concerned that echocardiography procedure codes
do not distinguish between services provided with contrast and those
provided without contrast, although section 1833(t)(2)(G) of the Act
requires that contrast and noncontrast procedures be paid through
separate APC groups. As echocardiography procedures are not usually
performed with contrast, the commenters asserted that the packaged
payment for contrast and echocardiography would be insufficient to
cover both costs, and that physicians would therefore be limited in
their ability to use contrast when necessary.
Response: The commenters are correct; section 1833(t)(2)(G) of the
Act requires us to create additional groups of services for procedures
that use contrast agents. As contrast agents were eligible for separate
payment in CY 2007 but subject to the OPPS drug packaging threshold, a
distinction was made in payment between those procedures performed with
contrast from those without contrast. However, as noted above, we are
finalizing our proposal to package all contrast agents in CY 2008
regardless of if they meet the OPPS drug packaging threshold.
[[Page 66644]]
Because current CPT codes do not distinguish between
echocardiography procedures performed without contrast from those
performed with contrast, we calculated HCPCS-specific median costs for
echocardiography procedures that were performed with contrast by
isolating single and ``pseudo'' single claims with CPT codes 93303
through 93350 where there was also a contrast agent on the claim. Our
analysis indicated that median costs for echocardiography procedures
performed with contrast are similar both clinically and in terms of
resource use, as evidenced by similar HCPCS median costs. Therefore,
pursuant to the statute, we have created APC 0128 (Echocardiogram With
Contrast) to provide payment for echocardiography procedures that are
performed with a contrast agent in CY 2008.
In order for hospitals to report echocardiography procedures
performed with contrast, as all contrast will be packaged in CY 2008,
we have also created the eight new HCPCS codes shown in Table 3 below.
We have assigned HCPCS codes C8921 through C8928 to the newly created
APC 0128. Hospitals performing echocardiography procedures without
contrast will continue to use the CPT codes indicated in Table 5, while
echocardiography procedures performed with contrast will be reported
with the newly developed C-codes also identified in Table 5. We will
provide further instruction about reporting echocardiography procedures
with and without contrast in the January 2007 OPPS update.
Table 5.--CY 2008 Echocardiography HCPCS Codes for Procedures With and Without Contrast
--------------------------------------------------------------------------------------------------------------------------------------------------------
Echocardiography without contrast Echocardiography with contrast
--------------------------------------------------------------------------------------------------------------------------------------------------------
HCPCS Descriptor SI APC HCPCS Descriptor SI APC
--------------------------------------------------------------------------------------------------------------------------------------------------------
93303............................... Transthoracic S 0269 C8921.................. Transthoracic S 0128
echocardiography for echocardiography with
congenital cardiac contrast for congenital
anomalies; complete. cardiac anomalies; complete.
93304............................... Transthoracic S 0697 C8922.................. Transthoracic S 0128
echocardiography for echocardiography with
congenital cardiac contrast for congenital
anomalies; follow-up or cardiac anomalies; follow-
limited study. up or limited study.
93307............................... Echocardiography, S 0269 C8923.................. Transthoracic S 0128
transthoracic, real-time echocardiography with
with image documentation contrast, real-time with
(2D) with or without M-mode image documentation (2D)
recording; complete. with or without M-mode
recording; complete.
93308............................... Echocardiography, S 0697 C8924.................. Transthoracic S 0128
transthoracic, real-time echocardiography with
with image documentation contrast, real-time with
(2D) with or without M-mode image documentation (2D)
recording; follow-up or with or without M-mode
limited study. recording; follow-up or
limited study.
93312............................... Echocardiography, S 0270 C8925.................. Transesophageal S 0128
transesophageal, real time echocardiography (TEE) with
with image documentation contrast, real time with
(2D) (with or without M- image documentation (2D)
mode recording); including (with or without M-mode
probe placement, image recording); including probe
acquisition, interpretation placement, image
and report. acquisition, interpretation
and report.
93313............................... Echocardiography, S 0270 ...... .....
transesophageal, real time
with image documentation
(2D) (with or without M-
mode recording); placement
of transesophageal probe
only.
93314............................... Echocardiography, N ...... ...... .....
transesophageal, real time
with image documentation
(2D) (with or without M-
mode recording); image
acquisition, interpretation
and report only.
93315............................... Transesophageal S 0270 C8926.................. Transesophageal S 0128
echocardiography for echocardiography (TEE) with
congenital cardiac contrast for congenital
anomalies; including probe cardiac anomalies;
placement, image including probe placement,
acquisition, interpretation image acquisition,
and report. interpretation and report.
93316............................... Transesophageal S 0270 ...... .....
echocardiography for
congenital cardiac
anomalies; placement of
transesophageal probe only.
93317............................... Transesophageal N ...... ...... .....
echocardiography for
congenital cardiac
anomalies; image
acquisition, interpretation
and report only.
93318............................... Echocardiography, S 0270 C8927.................. Transesophageal S 0128
transesophageal (TEE) for echocardiography (TEE) with
monitoring purposes, contrast for monitoring
including probe placement, purposes, including probe
real time 2-dimensional placement, real time 2-
image acquisition and dimensional image
interpretation leading to acquisition and
ongoing (continuous) interpretation leading to
assessment of (dynamically ongoing (continuous)
changing) cardiac pumping assessment of (dynamically
function and to therapeutic changing) cardiac pumping
measures on an immediate function and to therapeutic
time basis. measures on an immediate
time basis.
[[Page 66645]]
93320............................... Doppler echocardiography, N ...... ...... .....
pulsed wave and/or
continuous wave with
spectral display (List
separately in addition to
codes for echocardiographic
imaging); complete.
93321............................... Doppler echocardiography, N ...... ...... .....
pulsed wave and/or
continuous wave with
spectral display (List
separately in addition to
codes for echocardiographic
imaging); follow-up or
limited study (List
separately in addition to
codes for echocardiographic
imaging).
93325............................... Doppler echocardiography N ...... ...... .....
color flow velocity mapping
(List separately in
addition to codes for
echocardiography).
93350............................... Echocardiography, S 0697 C8928.................. Transthoracic S 0128
transthoracic, real-time echocardiography with
with image documentation contrast, real-time with
(2D), with or without M- image documentation (2D),
mode recording, during rest with or without M-mode
and cardiovascular stress recording, during rest and
test using treadmill, cardiovascular stress test
bicycle exercise and/or using treadmill, bicycle
pharmacologically induced exercise and/or
stress, with interpretation pharmacologically induced
and report. stress, with interpretation
and report.
--------------------------------------------------------------------------------------------------------------------------------------------------------
In order to determine a payment rate for APC 0128 for CY 2008, we
isolated single and ``pseudo'' single claims in our database that
included those CPT codes in the range of 93303 through 93350 that
correspond to the contrast studies described by the new C-codes. We
created new C-codes for contrast studies only to parallel those CPT
codes for procedures where we expected that the procedures could be
provided with or without contrast. For claims where an echocardiography
procedure was billed with a contrast agent, we packaged the payment for
the contrast agent into the echocardiography procedure and then
calculated the median cost for this subset of claims. This became the
median for APC 0128. In addition, we recalculated the medians for APCs
0269 (Level II Echocardiogram Without Contrast Except Transesophageal);
0270 (Transesophageal Echocardiogram Without Contrast); and 0697 (Level
I Echocardiogram Without Contrast Except Transesophageal), as we needed
to remove the claims from the ratesetting process that included
contrast because they were used to set the median cost for APC 0128.
The resulting CY 2008 APC medians are shown in Table 6.
Table 6.-CY 2008 Final Rule Echocardiogram APC Medians
------------------------------------------------------------------------
HCPCS
APC Title Codes Median
------------------------------------------------------------------------
0269......................... Level II 93303 $401
Echocardiogram 93307
Without Contrast
Except
Transesophageal.
0270......................... Transesophageal 93312 $517
Without Contrast 93313
Echocardiogram. 93315
93316
93318
0697......................... Level I 93304 $210
Echocardiogram 93308
Without Contrast 93350
Except
Transesophageal.
0128......................... Echocardiogram With C8921 $534
Contrast. C8922
C8923
C8924
C8925
C8926
C8927
C8928
------------------------------------------------------------------------
We believe that these medians accurately reflect hospital costs
when performing echocardiography procedures, both with and without
contrast. This final coding and payment methodology allows us to both
adhere to the statutory requirement to create additional groups of
services for procedures that use contrast agents and to package payment
contrast agents in CY 2008. Therefore, we are finalizing our policy to
assign HCPCS codes C8921
[[Page 66646]]
through C8928 to APC 0128 and will instruct hospitals to use these
contrast-specific HCPCS codes when submitting an OPPS claim for
echocardiography procedures performed with contrast.
For CY 2008, we are finalizing our proposal to unconditionally
packaged payment for all contrast agents, with modification as
discussed above. We are fully adopting the APC Panel recommendation to
package all contrast media for CY 2008. Consistent with the statute, we
are also finalizing the creation of APC 0128, as well as eight Level II
HCPCS codes that describe echocardiography procedures performed with
contrast. Contrast agents that are packaged are assigned status
indicator ``N'' and are listed in Table 10 of this final rule with
comment period.
(7) Observation Services
We proposed to package payment for all observation care, reported
under HCPCS code G0378 (Hospital observation services, per hour) for CY
2008. We proposed that payment for observation care would be packaged
as part of the payment for the separately payable services with which
it is billed. We have defined observation care as 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 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 or to patients with unexpectedly prolonged
recovery after surgery. Throughout the proposed rule and in this final
rule with comment period, as well as in our manuals and guidance
documents, we use both of the terms ``observation services'' and
``observation care'' in reference to the services defined above.
Payment for all observation care under the OPPS was packaged prior
to CY 2002. Since CY 2002, separate payment of a single unit of an
observation APC for an episode of observation care has been provided in
limited circumstances. Effective for services furnished on or after
April 1, 2002, separate payment for observation was made if the
beneficiary had chest pain, asthma, or congestive heart failure and met
additional criteria for diagnostic testing, minimum and maximum limits
to observation care time, physician care, and documentation in the
medical record (66 FR 59856, 59879). Payment for observation care that
did not meet these specified criteria was packaged. Between CY 2003 and
CY 2006, several more changes were made to the OPPS policy regarding
separate payment for observation services, such as: clarification that
observation is not separately payable when billed with ``T'' status
procedures on the day of or day before observation care; development of
specific Level II HCPCS codes for hospital observation services and
direct admission to observation care; and removal of the initially
established diagnostic testing requirements for separately payable
observation (67 FR 66794, 69 FR 65828, and 70 FR 68688). Throughout
this time period, we maintained separate payment for observation care
only for the three specified medical conditions, and OPPS payment for
observation for all other clinical conditions remained packaged.
Since January 1, 2006, hospitals have reported observation services
based on an hourly unit of care using HCPCS code G0378. This code has a
status indicator of ``Q'' under the CY 2007 OPPS, meaning that the OPPS
claims processing logic determines whether the observation is packaged
or separately payable. The OCE's current logic determines whether
observation services billed under HCPCS code G0378 are separately
payable through APC 0339 (Observation) or whether payment for
observation services will be packaged into the payment for other
separately payable services provided by the hospital in the same
encounter based on criteria discussed subsequently. (We note that if an
HOPD directly admits a patient to observation, Medicare currently pays
separately for that direct admission reported under HCPCS code G0379
(Direct admission of patient for hospital observation care) in
situations where payment for the actual observation care reported under
HCPCS code G0378 is packaged.) For CY 2008, as discussed in more detail
later in this final rule with comment period (section XI.), we proposed
to continue the coding and payment methodology for direct admission to
observation status, with the exception of the requirement that HCPCS
code G0379 is only eligible for separate payment if observation care
reported under HCPCS code G0378 does not qualify for separate payment.
As noted in the proposed rule (72 FR 42674), this requirement would no
longer be applicable under our proposal to package all observation
services reported under HCPCS code G0378.
For CY 2007, separate OPPS payment may be made for observation
services reported under HCPCS code G0378 provided to a patient when all
of the following requirements are met. The hospital would receive a
single separate payment for an episode of observation care (APC 0339)
when:
1. Diagnosis Requirements
a. The beneficiary must have one of three medical conditions:
congestive heart failure, chest pain, or asthma.
b. Qualifying ICD-9-CM diagnosis codes must be reported in Form
Locator (FL) 76, Patient Reason for Visit, or FL 67, principal
diagnosis, or both in order for the hospital to receive separate
payment for APC 0339. If a qualifying ICD-9-CM diagnosis code(s) is
reported in the secondary diagnosis field, but is not reported in
either the Patient Reason for Visit field (FL 76) or in the principal
diagnosis field (FL 67), separate payment for APC 0339 is not allowed.
2. Observation Time
a. Observation time must be documented in the medical record.
b. A beneficiary's time in observation (and hospital billing)
begins with the beneficiary's admission to an observation bed.
c. A beneficiary's time in observation (and hospital billing) ends
when all clinical or medical interventions have been completed,
including follow-up care furnished by hospital staff and physicians
that may take place after a physician has ordered the patient be
released or admitted as an inpatient.
d. The number of units reported with HCPCS code G0378 must equal or
exceed 8 hours.
3. Additional Hospital Services
a. The claim for observation services must include one of the
following services in addition to the reported observation services.
The additional services listed below must have a line-item date of
service on the same day or the day before the date reported for
observation:
An emergency department visit (APC 0609, 0613, 0614, 0615,
or 0616); or
A clinic visit (APC 0604, 0605, 0606, 0607, or 0608); or
Critical care (APC 0617); or
Direct admission to observation reported with HCPCS code
G0379 (APC 0604).
b. No procedure with a ``T'' status indicator can be reported on
the same day or day before observation care is provided.
4. Physician Evaluation
a. The beneficiary must be in the care of a physician during the
period of
[[Page 66647]]
observation, as documented in the medical record by admission,
discharge, and other appropriate progress notes that are timed,
written, and signed by the physician.
b. The medical record must include documentation that the physician
explicitly assessed patient risk to determine that the beneficiary
would benefit from observation care.
In the context of our proposed CY 2008 packaging approach, we
indicated that we believed that it was appropriate to package payment
for all observation services reported with HCPCS code G0378 under the
CY 2008 OPPS. Primarily, observation services are ideal for packaging
because they are always provided as a supportive service in conjunction
with other independent separately payable hospital outpatient services
such as an emergency department (ED) visit, surgical procedure, or
another separately payable service, and thus observation costs can
logically be packaged into OPPS payment for independent services. As
discussed extensively in this section, packaging payment into larger
payment bundles creates incentives for providers to furnish services in
the most efficient way that meets the needs of the patient, encouraging
long-term cost containment.
As we discussed in the general overview of the CY 2008 packaging
approach (section II.A.4.b. of this final rule with comment period),
there has been substantial growth in program expenditures for hospital
outpatient services under the OPPS in recent years. The primary reason
for this upsurge is growth in the intensity and utilization of services
rather than the general price of services or enrollment changes. This
observed trend is notably reflected in the frequency and costs of
separately payable observation care for the last few years. While
median costs for an episode of observation care that would meet the
criteria for separate payment have remained relatively stable between
CYs 2003 and 2006, the frequency of claims for separately payable
observation services has rapidly increased. Comparing claims data for
separately payable observation care available for proposed rules
spanning from CYs 2005 to 2008 (that is, claims data reflecting
services furnished from CYs 2003 to 2006), we saw substantial growth in
separately payable observation care billed under the OPPS over that
time. In CY 2003, the first full year that observation care was
separately payable, there were approximately 56,000 claims for
separately payable observation care. In CY 2004, there were
approximately 77,000 claims for separately payable observation care. By
CY 2005, that number had increased to approximately 124,300 claims,
representing an increase of approximately 61 percent over the previous
calendar year. Based on the CY 2006 data available for issuance of the
proposed rule, the frequency of claims for separately payable
observation services increased to more than 271,200 claims which
represents an increase of approximately 118 percent over CY 2005 and
more than triple the number of claims for CY 2004. While it is not
possible to discern the specific factors responsible for the growth in
claims for separately payable observation services, as there have been
minor changes in both the process and criteria for separate payment for
these services over this time period, the substantial growth by itself
is noteworthy.
In the proposed rule (72 FR 42675), we indicated that we were also
concerned that the current criteria for separate payment for
observation services may provide disincentives for efficiency. For CY
2007, in order for observation services to be separately payable, they
must last at least 8 hours. While this criterion was put in place to
ensure that separate payment is made only for observation services of a
substantial duration, it may create a financial disincentive for an
HOPD to make a timely determination regarding a patient's safe
disposition after observation care ends. By packaging payment for all
observation services, regardless of their duration, we would provide
incentives for more efficient delivery of services and timely decision-
making. The current criterion also prohibits separate payment for
observation services when a ``T'' status procedure (generally a
surgical procedure) is provided on the same day or the previous day by
the HOPD to the same Medicare beneficiary. Again, this may create a
financial disincentive for hospitals to provide minor surgical
procedures during a patient's observation stay, unless those procedures
are essential to the patient's care during that time period, even if
the most efficient and effective performance of those procedures could
be during the single HOPD encounter.
Currently, the OPPS pays separately for observation care for only
the three original medical conditions designated in CY 2002,
specifically chest pain, asthma, and congestive heart failure. As
discussed in more detail in the observation section (section XI.) of
this final rule with comment period, the APC Panel recommended at its
March 2007 meeting that we consider expanding separate payment for
observation services to include two additional diagnoses, syncope and
dehydration. As mentioned previously, we have defined observation care
as a well-defined set of specific, clinically appropriate services,
which include ongoing, short term treatment, assessment, and
reassessment, that are furnished while a decision is being made
regarding whether a patient will require further treatment as a
hospital inpatient or if the individual is able to be discharged from
the hospital. Given the definition of observation services, it is clear
that, in certain circumstances, observation care could be appropriate
for patients with a range of diagnoses. Both the APC Panel and numerous
commenters to prior OPPS proposed rules have confirmed their agreement
with this perspective. In addition, the June 2006 Institute of Medicine
(IOM) Report entitled, ``Hospital-Based Emergency Care: At the Breaking
Point,'' encourages hospitals to apply tools to improve the flow of
patients through emergency departments, including developing clinical
decisions units where observation care is provided. The IOM's Committee
on the Future of Emergency Care in the United States Health System
recommended that CMS remove the current limitations on the medical
conditions that are eligible for separate observation care payment in
order to encourage the development of such observation units.
We indicated in the proposed rule (72 FR 42676) that, as packaging
payment provides desirable incentives for greater efficiency in the
delivery of health care and provides hospitals with significant
flexibility to manage their resources, we believed it was most
appropriate to treat observation care for all diagnoses similarly by
packaging its costs into payment for the separately payable independent
services with which the observation is associated. We noted in the
proposed rule (72 FR 42676) that this consistent payment methodology
would provide hospitals with the flexibility to assess their approaches
to patient care and patient flow and provide observation care for
patients with a variety of clinical conditions when hospitals conclude
that observation services would improve their treatment of those
patients. Approximately 70 percent of the occurrences of observation
care billed under the OPPS are currently packaged, and this expansion
would extend the incentives for efficiency already present for the vast
majority of observation services that are already packaged under the
OPPS to the remaining 30 percent of
[[Page 66648]]
observation services for which we currently make separate payment.
The estimated overall impact of these changes, presented in section
XXII.B. of the proposed rule (and in section XXIV.B. of this final rule
with comment period), was based on the assumption that hospital
behavior would not change with regard to when the dependent observation
care is provided in the same encounter and by the same hospital that
performs the independent services. To the extent that hospitals could
change their behavior and cease providing observation services, refer
patients elsewhere for that care, or increase the frequency of
observation services, the data would show such a change in practice in
future years and that change would be reflected in future budget
neutrality adjustments. However, with respect to observation care, we
indicated that we believe that hospitals are limited in the extent to
which they could change their behavior with regard to how they furnish
these services because observation care, by definition, is 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 after
receiving the independent services. We indicated that we believe it is
unlikely that hospitals will cease providing medically necessary
observation care or refer patients elsewhere for that care if they were
unable to reach a decision that the patient could be safely discharged
from the outpatient department. We stated in the proposed rule (72 FR
42677) that we expect that hospitals would always bill the supportive
observation services on the same claim as the other independent
services provided in the single hospital encounter.
As we indicated earlier, in all cases we proposed that hospitals
that furnish the observation care in association with independent
services must bill those services on the same claim so that the costs
of the observation services can be appropriately packaged into payment
for the independent services. We stated in the proposed rule (72 FR
42677) that we expected to carefully monitor any changes in billing
practices on a service-specific and hospital-specific basis to
determine whether there is reason to request that QIOs review the
quality of care furnished or to request that Program Safeguard
Contractors review the claims against the medical record.
During its September 2007 APC Panel meeting, the APC Panel
recommended that CMS not package observation services as proposed,
thereby maintaining the CY 2007 payment policy. However, the APC Panel
indicated that if CMS were to package observation, CMS should create a
composite emergency department/clinic and observation APC (or group of
composite APCs) that would be paid only when both services were
furnished; if the composite APC were paid, neither the emergency
department nor the clinic visit would be paid separately. The APC Panel
recommended that coding and service requirements currently applicable
to separately paid observation would remain the same, with the
exception that there would be no clinical condition (that is,
diagnosis) restrictions on payment for the composte APC. The APC Panel
noted that payment rates for this (these) composite APC(s) would need
to be adjusted based on readily available historical visit and
observation data.
We received many public comments on our proposal to package payment
for observation services into the payment for the services with which
it is furnished. A summary of public comments and our responses follow.
Comment: Several commenters, including MedPAC, requested that CMS
finalize its policy to package payment for all observation care. MedPAC
specifically stated that packaging of observation care is logical
because currently 70 percent of observation care is packaged. However,
most commenters addressing observation packaging requested that CMS
finalize its proposal to package all of the categories of codes that it
identified in the proposed rule, with the exception of observation
care. Many of these commenters stated that observation care is often a
significant service and is not supportive and integral to an
independent service. These commenters recommended that CMS implement
various policies, such as paying separately for all observation care
regardless of diagnosis, expanding the diagnoses that would enable
separate payment, postponing packaging observation services, or
creating a composite APC to allow separate payment for observation care
in certain circumstances.
Response: Based on our review of the comments received, we continue
to believe that observation services are usually ancillary and
supportive to the other independent services that are provided to the
patient on the same day. However, we accept the commenters' and the APC
Panel's statements that observation care may sometimes rise to the
level of a major component service, specifically, when it is provided
for 8 hours or more in association with a high level clinic or ED
visit, direct admission to observation, or critical care services and
it is not provided in conjunction with a surgical procedure. In
addition, based on our review of the clinical circumstances provided by
many commenters, we recognize that observation care can be a major
component service when provided to patients with clinical conditions
other than congestive heart pain, chest pain, and asthma for which
separate observation payment may currently by provided under the OPPS.
Consistent with our statutory flexibility to define what
constitutes a service under the OPPS, we proposed to view a service, in
some cases, as the totality of care provided in a hospital outpatient
encounter that would be reported with two or more HCPCS codes for
component services with the proposal of composite APCs for low dose
rate prostate brachytherapy and cardiac electrophysiological evaluation
and ablation services. In general, we intend to request public comment
on possible composite APCs in the annual OPPS proposed rulemaking
cycle. This also includes creating composite APCs, as appropriate, in
response to those public comments received during rulemaking.
Therefore, we have decided to create two composite APCs that will
provide payment to hospitals in certain circumstances when extended
assessment and management of a patient occur. These composite APCs
describe an extended encounter for care provided to a patient.
Specifically, we are creating two new composite APCs for CY 2008, APCs
8002 (Level I Extended Assessment and Management Composite) and 8003
(Level II Extended Assessment and Management Composite). APC 8002
describes an encounter for care provided to a patient that includes a
high level (Level 5) clinic visit or direct admission to observation in
conjunction with observation services of substantial duration. APC 8003
describes an encounter for care provided to a patient that includes a
high level (Level 4 or 5) emergency department visit or critical care
services in conjunction with observation services of substantial
duration. As with the other composite APCs that we proposed, we
anticipate that assignment to and payment through one of these two new
composite APCs will be transparent from a billing perspective. The OCE
will evaluate every claim received to determine if payment through a
composite APC is appropriate. If payment through a composite APC is
inappropriate, the OCE in conjunction with the PRICER, will determine
the appropriate status
[[Page 66649]]
indicator, APC, and payment for every code on a claim. The specific
logic associated with the two Extended Assessment and Management
Composite APCs is detailed below.
APC 8002 will be assigned when 8 or more units of HCPCS code G0378
(Hospital observation service, per hour) are billed--
On the same day as HCPCS code G0379 (Direct admission of
patient for hospital observation care); or
On the same day or the day after--
++ CPT code 99205 (Office or other outpatient visit for the
evaluation and management of a new patient (Level 5)); or
++ CPT code 99215 (Office or other outpatient visit for the
evaluation and management of an established patient (Level 5)).
If a hospital provides a service with status indicator ``T'' on the
same date of service, or 1 day earlier than the date of service
associated with HCPCS code G0378, the hospital will not be eligible for
payment under APC 8002. There is no diagnosis requirement for purposes
of this composite APC. Rather, patients with any diagnosis may trigger
payment of APC 8002. If any of the criteria listed above are not met,
payment would not be made through APC 8002. Instead, payment for any
separately payable services, including the clinic visit, would be made
through the usual associated APCs. Payment for a direct admission to
observation would be made according to the usual HCPCS code G0379
payment criteria and payment for HCPCS code G0378 would remain packaged
because we consider the observation care to be supportive and ancillary
to whichever service(s) it accompanies.
APC 8003 will be assigned when eight or more units of HCPCS code
G0378 (Hospital observation service, per hour) are billed on the same
day or the day after CPT code 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)); or 99291 (Critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes). The
remaining criteria are identical to the criteria associated with
composite APC 8002. If a hospital provides a service with status
indicator ``T'' on the same date of service, or one day earlier than
the date of service associated with HCPCS code G0378, the composite APC
8003 would not apply. Instead, payment for the ED visit or critical
care and any other separately payable services will be made through the
usual associated APCs, and payment for HCPCS code G0378 for observation
services will remain packaged because we consider the observation care
to be supportive and ancillary to whichever service(s) it accompanies.
There is no diagnosis requirement for purposes of this composite APC
either. Instead, patients with any diagnosis may trigger payment of APC
8003.
We note that HCPCS code G0378 will continue to be assigned status
indicator ``N,'' signifying that its payment is always packaged. As
stated above, in most circumstances, observation services are
supportive and ancillary to the other services provided to a patient.
In the circumstances when observation care is elevated to a major
component service in conjunction with a high level visit or direct
admission that is an integral part of a patient's extended encounter
for care, payment is made for the entire care encounter through APC
8002 or 8003, as appropriate.
We are retaining as general reporting requirements for all
observation services those criteria related to physician order and
evaluation, documentation, and observation beginning and ending time as
listed in section XI. of this final rule with comment period. Those are
more general requirements that encourage hospitals to provide medically
reasonable and necessary care and help to ensure the proper reporting
of observation services on correctly coded hospital claims that reflect
the full charges associated with all hospital resources utilized to
provide the reported services.
The CY 2008 median cost for APC 8002 (Level I Extended Assessment
and Management Composite) is approximately $347. The payment associated
with APC 8002 is intended to pay the hospital for the costs associated
with a single episode of extended assessment and management that
includes a high level clinic visit or direct admission to the hospital
for observation care, 8 hours or more of observation services, and any
associated packaged services. We calculated this median cost using all
CY 2006 single bill claims that met the criteria for APC 8002, as
specified above. The CY 2008 median cost for APC 8003 (Level II
Extended Assessment and Management Composite) is approximately $631.
The payment associated with APC 8003 is intended to pay the hospital
for the costs associated with a single episode of more intense extended
assessment and management that includes a high level emergency
department visit or critical care services, 8 hours or more of
observation services, and any associated packaged services. We
calculated this median cost using all CY 2006 single bill claims that
met the criteria for APC 8003, as specified above.
While analyzing CY 2006 claims data, the most current full year
claims data available, we observed that applying CY 2008 criteria for
composite APCs resulted in payment for 55 percent more instances of
observation care through a composite APC than if we had applied the CY
2007 criteria to those same claims. In addition, our CY 2006 claims
data indicate that close to 30 percent of all observation care was paid
separately. We estimate that roughly 90 percent of those instances of
separately payable observation care reported in CY 2006 would be
eligible for payment through composite APCs 8002 and 8003, using CY
2008 criteria. Those separately payable observation services that would
not be eligible for payment through a composite APC involve observation
services that were associated with low level clinic or emergency
department visits. In addition, some of the packaged observation care
that was provided in CY 2006 would be eligible for payment through
composite APCs 8002 and 8003 because we are eliminating the diagnosis
requirement for CY 2008.
As noted in detail in section IX.C of this final rule with comment
period, we see a normal and stable distribution of clinic and ED visit
levels. We do not expect this distribution to change due to the
increase in claims for high level visits that may result from the new
composite APCs. Depending on our CY 2008 claims data (which would be
used for the CY 2010 OPPS), we may choose to modify the composite APCs
that we are creating for CY 2008 or move to packaging observation care
as we originally proposed to create further incentives for hospitals to
operate in an efficient way.
In summary, for CY 2008, payment for observation services will
remain packaged with status indicator ``N.'' We are creating two
composite APCs for extended assessment and management, of which
observation care is a component major service. When criteria for
payment of the composite APCs are met, separate payment will be made to
the hospital through the composite APC. This composite APC payment
methodology will contribute to our goal of providing payment under the
OPPS for a larger bundle of component services provided in a single
hospital outpatient encounter, creating additional hospital incentives
for efficiency and cost containment, while providing hospitals with the
most flexibility to manage their resources.
[[Page 66650]]
d. Development of Composite APCs
(1) Background
As we discuss above in regard to our reasons for our packaging
approach for the CY 2008 OPPS, we believe that it is crucial that the
payment approach of the OPPS create incentives for hospitals to seek
ways to provide services more efficiently than exist under the current
OPPS structure and allow hospitals maximum flexibility to manage their
resources. The current OPPS structure usually provides payment for
individual services which are generally defined by individual HCPCS
codes. We currently package the costs of some items and services (such
as drugs and biologicals with an average per day cost of less than $55)
into the payment for separately payable individual services. However,
because the extent of packaging in the OPPS is currently modest,
furnishing many individual separately payable services increases total
payment to the hospital. We believe that this aspect of the current
OPPS structure is a significant factor in the growth in volume and
spending that we discuss in our general overview and provides a primary
rationale for the packaging approach for services that we proposed for
the CY 2008 OPPS. While packaging payment for supportive dependent
services into the payment for the independent services which they
accompany promotes greater efficiency and gives hospitals some
flexibility to manage their resources, we believe that payment for
larger bundles of major separately paid services that are commonly
performed in the same hospital outpatient encounter or as part of a
multi-day episode of care would create even more incentives for
efficiency, as discussed earlier. Moreover, defining the ``service''
paid under the OPPS by combinations of HCPCS codes for component
services that are commonly performed in the same encounter and that
result in the provision of a complete service would enable us to use
more claims data and to establish payment rates that we believe more
appropriately capture the costs of services paid under the OPPS.
Section 1833(t)(1)(B) of the Act permits us to define what
constitutes a ``service'' for purposes of payment under the OPPS and is
not restricted to defining a ``service'' as a single HCPCS code. For
example, the OPPS currently packages payment for certain items and
services reported with HCPCS codes into the payment for other
separately payable services on the claim. Consistent with our statutory
flexibility to define what constitutes a service under the OPPS, we
proposed to view a service, in some cases, as not just the diagnostic
or treatment modality identified by one individual HCPCS code but as
the totality of care provided in a hospital outpatient encounter that
would be reported with two or more HCPCS codes for component services.
In view of this statutory flexibility to define what constitutes a
``service'' for purposes of OPPS payment, our desire to encourage
efficiency in HOPD care, our focus on value-based purchasing, and our
desire to use as much claims data as possible to set payment rates
under the OPPS, we examined our claims data to determine how we could
best use the multiple procedure claims (``hardcore'' multiples) that
are otherwise not available for ratesetting because they include
multiple separately payable procedures furnished on the same date of
service. As discussed in more detail in our discussion of single and
multiple procedure claims in section II.A.1.b. of this final rule with
comment period, we have focused in recent years on ways to convert
multiple procedure claims to single procedure claims to maximize our
use of the claims data in setting median costs for separately payable
procedures. We have been successful in using the bypass list to
generate ``pseudo'' single procedure claims for use in median setting,
but this approach generally does not enable us to use the hardcore
multiple claims that contain multiple separately payable procedures,
all with associated packaging that cannot be split among them. We
believe that we could use the data from many more multiple procedure
claims by creating APCs for payment of those services defined as
frequently occurring common combinations of HCPCS codes for component
services that we see in correctly coded multiple procedure claims.
Our examination of data for multiple procedure claims identified
two specific sets of services that we believe are good candidates for
payment based on the naturally occurring common combinations of
component codes that we see on the multiple procedure claims. These are
low dose rate (LDR) prostate brachytherapy and cardiac
electrophysiologic evaluation and ablation services.
Specifically, we have been told (and our data support) that claims
for LDR prostate brachytherapy, when correctly coded, report at least
two major separately payable procedure codes the majority of the time.
For reasons discussed below, in the CY2008 OPPS/ASC proposed rule (72
FR 42678 through 42679), we proposed to use these correctly coded
claims that would otherwise be unusable hardcore multiples as the basis
for an encounter-based composite APC that would make a single payment
when both codes are reported with the same date of service. We also
proposed to pay separately for these procedure codes in cases where
only one of the two procedures is provided in a hospital encounter,
through the APC associated with that component procedure code that is
furnished.
Similarly, we have been told (and our data support) that multiple
cardiac electrophysiologic evaluation, mapping, and ablation services
are typically furnished on the same date of service and that the
correctly coded claims are typically the multiple procedure claims that
include several component services and that we are unable to use in our
current claims process. The CY 2007 CPT book introductory discussion in
the section entitled ``Intracardiac Electrophysiological Procedures/
Studies'' notes that, in many circumstances, patients with arrhythmias
are evaluated and treated at the same encounter. Therefore, as
discussed in detail below, we also proposed to establish an encounter
based composite APC for these services that would provide a single
payment for certain common combinations of component cardiac
electrophysiologic services that are reported on the same date of
service.
These composite APCs reflect an evolution in our approach to
payment under the OPPS. Where the claims data show that combinations of
services are commonly furnished together, in the future we will
actively examine whether it would be more appropriate to establish a
composite APC under which we would pay a single rate for the service
reported with a combination of HCPCS codes on the same date of service
(or different dates of service) than to continue to pay for these
individual services under service-specific APCs. We proposed these
specific encounter-based composite APCs for CY 2008 because we believe
that this approach could move the OPPS toward possible payment based on
an encounter or episode-of-care basis, enable us to use more valid and
complete claims data, create hospital incentives for efficiency, and
provide hospitals with significant flexibility to manage their
resources that do not exist when we pay for services on a per service
basis. As such, we indicated that these proposed composite APCs may
serve as a prototype for future creation of more composite APCs,
through which we could provide OPPS payment for other types of services
in the future. We
[[Page 66651]]
noted that while these proposed composite APCs for CY 2008 are based on
observed combinations of component HCPCS codes reported on the same
date of service for a single encounter, we also would be exploring in
the future how we could potentially set payments based on episodes of
care involving services that extend beyond the same date but which are
all supportive of a single, related course of treatment. While we did
not propose to implement multiday episode-of-care APCs in CY 2008, we
welcomed comments on the concept of developing these APCs to provide
payment for such episodes in order to inform our future analyses in
this area.
While we have never previously used the term ``composite'' APC
under the OPPS, we have one historical payment policy that resembles
the CY 2008 proposed composite APC policy. Since the inception of the
OPPS, CMS has limited the aggregate payment for specified less
intensive mental health services furnished on the same date to the
payment for a day of partial hospitalization, which we considered to be
the most resource intensive of all outpatient mental health treatment
(65 FR 18455). The costs associated with administering a partial
hospitalization program represent the most resource intensive of all
outpatient mental health treatment, and we do not believe that we
should pay more for a day of individual mental health services under
the OPPS. Through the OCE, when the payment for specified mental health
services provided by one hospital to a single beneficiary on one date
of service based on the payment rates associated with the APCs for the
individual services would exceed the per diem partial hospitalization
payment (listed as APC 0033 (Partial Hospitalization)), those specified
mental health services are assigned to APC 0034, which has the same
payment rate as APC 0033, and the hospital is paid one unit of APC
0034. This longstanding policy regarding payment of APC 0034 for
combinations of independent services provided in a single hospital
encounter resembles the payment policy for composite APCs that we
proposed for LDR prostate brachytherapy and cardiac electrophysiologic
evaluation and ablation services for CY 2008. Similar to the logic for
the proposed composite APCs, the OCE determines whether to pay these
specified mental health services individually or to make a single
payment at the same rate as the per diem rate for partial
hospitalization for all of the specified mental health services
furnished on that date of service. However, we note this established
policy for payment of APC 0034 differs from the proposed policies for
the new CY 2008 composite APCs because APC 0034 is only paid if the sum
of the individual payment rates for the specified mental health
services provided on one date of service exceeds the APC 0034 payment
rate, which equals the per diem rate of APC 0033 for partial
hospitalization.
We did not propose to change this mental health services payment
policy for CY 2008. However, we proposed to change the status indicator
from ``S'' to ``Q'' for the HCPCS codes for the specified mental health
services to which APC 0034 applies because those codes are
conditionally packaged when the sum of the payment rates for the single
code APCs to which they are assigned exceeds the per diem payment rate
for partial hospitalization. While we have not published APC 0034 in
Addendum A in the past, we are including it in Addendum A to this final
rule with comment period entitled ``Mental Health Composite,''
consistent with our naming taxonomy and publication of the two other
composite APCs. We are also including the mental health composite APC
0034 and its member HCPCS codes in Addendum M to this final rule with
comment period in the same way that we show the HCPCS codes to which
the LDR Prostate Brachytherapy Composite APC and Cardiac
Electrophysiologic Evaluation and Ablation Composite APC apply.
We solicited public comments on the concept of composite APCs in
general and, specifically, the two new proposed encounter-based
composite APCs for CY 2008, and we expressed our hope of involving the
public and the APC Panel in the creation of additional composite APCs.
As stated in the proposed rule (72 FR 42679), our goal is to use the
many naturally occurring multiple procedure claims that cannot
currently be incorporated under the existing APC structure, regardless
of whether the naturally occurring pattern of multiple procedure claims
prevents the development of single bills for individual services.
We received many comments on the concept of composite APCs in
general and on the proposal to create the LDR Prostate Brachytherapy
Composite and the Electrophysiologic Evaluation and Ablation Composite
APC in particular. A summary of the comments and our responses follow.
Comment: In general, most commenters supported the creation of the
two composite APCs that were proposed for CY 2008: Cardiac
Electrophysiologic Evaluation and Ablation Composite (APC 8000) and Low
Dose Rate Prostate Brachytherapy Composite (APC 8001). Commenters,
including MedPAC and the APC Panel, supported the implementation of the
proposed composite APCs. Commenters stated that creation of these
composites will enable use of more multiple claims data and enable the
payment system to better reflect the reality of how services are
commonly furnished. In particular, MedPAC indicated that it supports
the proposed composite APCs because they will increase incentives for
efficiency and can serve as a starting point for payment bundles that
reflect encounters or episodes of care. MedPAC indicated that it will
be exploring both packaging and bundling under the OPPS in its future
work. Other commenters objected to the creation of composite APCs
because they believed that they are dependent on proposed packaging
changes that the commenters do not support. Other commenters supported
the concept of composite APCS as long as a composite is limited to
related services furnished on the same date of service. These
commenters believed that the creation of composite APCs for
discontinuous services that span multiple dates of service would
present too many problems to be viable.
Response: We appreciate the commenters' support for the creation of
the two proposed composite APCs and we will implement the proposed new
composite APCs 8000 and 8001 for services furnished on and after
January 1, 2008. We also acknowledge that the viability of the
composite APCs is dependent on packaging of the supportive and
ancillary services. However, as discussed above, we are finalizing the
proposed packaging approach, with modifications, and therefore, we
believe that it is appropriate to finalize the creation of these two
composite APCs for the CY 2008 OPPS. We will take the commenters'
concerns with regard to the possible creation of composite APCs for
discontinuous services that span multiple dates of service into account
in development of future proposals for composite APCs.
Comment: Some commenters asked that CMS provide a clear and
transparent process for identifying and calculating payments for future
composite APCs and asked that CMS evaluate closely the impact of the
proposed composites on payment adequacy and access to care before
expanding to other services. They asserted that any development of
further composite APCs should include the views of all stakeholders.
Response: We expect that in the future, we would identify possible
[[Page 66652]]
composite APCs using the same process that we used to identify the
codes in composite APCs 8000 and 8001. As we described in the proposed
rule, we examined the multiple procedure claims that we could not
convert to single procedure claims to identify common combinations of
services for which we had relatively few single procedure claims. We
then performed a clinical assessment of the combinations that we
identified to determine whether our findings were consistent with our
understanding of the services furnished. After we defined the minimal
combination of services for which we would pay under the composite APC,
we then identified claims for which the only separately paid codes were
members of the composite, and we calculated the median cost for the
package of services, including the costs of the packaged services. We
intend to proceed carefully in examining the potential for creation of
more composite APCs. In general, we intend to follow this process for
creation of composite APCs and to request public comment in the
rulemaking cycle, which is our standard process for securing the views
of stakeholders. See section II.A.4.c.(7). for our discussion of the
composite APCs we created for this final rule with comment period,
specifically APC 8002 (Level I Extended Assessment and Management
Composite) and APC 8003 (Level II Extended Assessment and Management
Composite).
Comment: Some commenters asked that CMS ensure that all packaged
costs are captured in the payment rate for the composite APC. Other
commenters stated that there are many intraoperative services that we
proposed to package that may or may not be done at the same time and
whose costs, when packaged may not be fully accommodated in the
composite payment and should therefore be paid separately in addition
to the payment for the composite APCs. Some commenters identified
services that CMS proposed to package for which they believed separate
payment should be made outside of the composite APC payment. For
example, one commenter asked that CPT code 93662 (Intracardiac
echocardiography during therapeutic/diagnostic intervention, including
imaging supervision and interpretation (List separately in addition to
code for primary procedure)) continue to be paid separately and not as
part of composite APC 8000 because its cost is high but the frequency
of its use with the main procedures in APC 8000 is low.
Response: We capture the packaged costs in the creation of the
composite APC medians to the extent that the packaged services are
reported on the claims that meet the criteria for composite payment.
The effectiveness of the composite APCs is highly dependent upon the
packaging of the ancillary and supportive services that are furnished
at the same encounter with the services in the composite APC. By
packaging guidance, imaging post processing, intraoperative, and
imaging supervision and interpretation services we are able to identify
many more services that contain only the separately paid procedures
that are assigned to the composite APC that we can then use to
calculate a median cost for the composite APC. Separate payment for
guidance, imaging post processing, intraoperative, and imaging
supervision and interpretation services would greatly reduce the number
of claims that would be available for use in composite APCs because the
HCPCS codes assigned to the composite APC would no longer be the only
separately paid procedure codes on the claims and one of the benefits
of using a composite APC (enabling use of more claims) would be lost.
As with packaging of the costs of OPPS services in general, we package
costs into the cost of the major separately paid service being
furnished. In the case of the composite APCs, the costs of ancillary
and dependent services are packaged into the payment for the composite
APC to the extent that they are furnished with the services that are
assigned to the composite APC. In general, the premise of the OPPS,
like that of other claims-based prospective payment systems, is that
hospitals report HCPCS codes and charges to reflect the reality of how
they furnish services. In general, we believe we can rely on the claims
data to be an accurate reflection of the services that were furnished
to Medicare beneficiaries.
Comment: A commenter stated that the composite APCs differ
significantly in concept from the conditionally packaged services to
which CMS also proposed to assign status indicator ``Q'' and urged CMS
to assign a status indicator other than ``Q'' to composites so that
they would be more easily distinguishable from a conditionally packaged
service. Other commenters stated that the definition of the status
indicator Q was ill defined and confusing.
Response: For CY 2008, we will assign the status indicator ``Q'' to
composite APCs, to codes that are packaged when billed on the same
claim with a procedure that has status indicator ``S,'' ``T,'' ``V,''
or ``X,'' and to codes that are packaged only when billed on the same
claim with a procedure that has a status indicator ``T.'' We will
consider for CY 2009 whether it would be more appropriate to assign
status indicators based on the particular packaging policy that applies
to the code.
We appreciate the comments on composite APCs. With respect to our
treatment of mental health services, we are not making a change to the
longstanding payment policy under which the OPPS pays one unit of APC
0034 in cases in which the total payments for specified mental health
services provided on the same date of service would otherwise exceed
the payment rate for APC 0033. However, we are changing the status
indicator to ``Q'' for the HCPCS codes for mental health services to
which this policy applies and which comprise this existing composite
APC, because payment for these services would be packaged unless the
sum of the individual payments assigned to the codes would be less than
the payment for APC 0034.
(2) Low Dose Rate (LDR) Prostate Brachytherapy Composite APC
(a) Background
LDR prostate brachytherapy is a treatment for prostate cancer in
which needles or catheters are inserted into the prostate, and then
radioactive sources are permanently implanted into the prostate through
the hollow needles or catheters. The needles or catheters are then
removed from the body, leaving the radioactive sources in the prostate
forever, where they slowly give off radiation to destroy the cancer
cells until the sources are no longer radioactive. At least two CPT
codes are used to report the composite treatment service because there
are separate codes that describe placement of the needles or catheters
and application of the brachytherapy sources. LDR prostate
brachytherapy cannot be furnished without the services described by
both of these codes. Generally, the component services represented by
both codes occur in the same operative session in the same hospital on
the same date of service. However, we have been told of uncommon cases
in which they are furnished in different locations, with the patient
being transported from one location to another for application of the
sources. In addition, other services, commonly CPT code 76965
(Ultrasonic guidance for interstitial radioelement application) and CPT
code 77290 (Therapeutic radiology simulation-aided field setting;
complex) are often provided in the same hospital encounter.
CPT code 55875 (Transperineal placement of needles or catheters
into
[[Page 66653]]
prostate for interstitial radioelement application, with or without
cystoscopy) is used to report the placement of the needles or catheters
for services furnished on or after January 1, 2007. Before this date,
including in the claims for services furnished in CY 2006 that were
used to develop the CY 2008 proposed rule, CPT code 55859
(Transperineal placement of needles or catheters into prostate for
interstitial radioelement application, with or without cystoscopy)
reported this service. All of the claims for CPT code 55859 (as
reported in the CY 2006 claims data) are for the placement of needles
or catheters for prostate brachytherapy, although not all are related
to permanent brachytherapy source application.
CPT code 77778 (Interstitial radiation source application; complex)
is used to report the application of brachytherapy sources and, when
billed with CPT code 55859 (or CPT code 55875 after January 1, 2007)
for the same encounter, reports placement of the sources in the
prostate. We have been told that application of brachytherapy sources
to the prostate is estimated to be about 85 percent of all occurrences
of CPT code 77778 under the OPPS, consistent with our CY 2006 claims
data used for CY 2008 ratesetting. CPT code 77778 is also used to
report the application of sources of brachytherapy to body sites other
than the prostate.
Historical coding, APC assignments, and payment rates for CPT codes
55859 (CPT code 55875 beginning in CY 2007) and 77778 are shown below
in Table 7.
Table 7.--Historical Payment Rates for Complex Interstitial Application of Brachytherapy Sources
--------------------------------------------------------------------------------------------------------------------------------------------------------
Payment Payment
rate for APC for rate for APC for
OPPS CY Combination APC CPT code HCPCS code CPT codes HCPCS code Brachytherapy source
77778 77778 55859/55875 55859
--------------------------------------------------------------------------------------------------------------------------------------------------------
2000..................................... n/a......................... $198.31 APC 0312 $848.04 APC 0162 Pass-through
2001..................................... n/a......................... $205.49 APC 0312 $878.72 APC 0162 Pass-through
2002..................................... n/a......................... $6,344.67 APC 0312 $2,068.23 APC 0163 Pass-through with pro rata
reduction
2003 (prostate brachytherapy with iodine G0261, APC 648, $5,154.34... n/a n/a n/a n/a Packaged
sources).
2003 (prostate brachytherapy with G0256, APC 649, $5,998.24... n/a n/a n/a n/a Packaged
palladium sources).
2003 (not prostate brachytherapy, not N/A......................... $2,853.58 APC 0651 $1,479.60 APC 0163 Separate payment based on
including sources). scaled median cost per
source
2004..................................... N/A......................... $558.24 APC 0651 $1,848.55 APC 0163 Cost
2005..................................... N/A......................... $1,248.93 APC 0651 $2,055.63 APC 0163 Cost
2006..................................... N/A......................... $666.21 APC 0651 $1,993.35 APC 0163 Cost
2007..................................... N/A......................... $1,035.50 APC 0651 $2,146.84 APC 0163 Cost
--------------------------------------------------------------------------------------------------------------------------------------------------------
Payment rates for CPT code 77778, in particular, have fluctuated
over the years. We have frequently been informed by the public that
reliance on single procedure claims to set the median costs for these
services results in use of only incorrectly coded claims for LDR
prostate brachytherapy because, for application of brachytherapy
sources to the prostate, a correctly coded claim is a multiple
procedure claim. Specifically, we have been informed that a correctly
coded claim for LDR prostate brachytherapy should include, for the same
date of service, both CPT codes 55859 and 77778, brachytherapy sources
reported with Level II HCPCS codes, and typically separately coded
imaging and radiation therapy planning services, and that we should use
correctly coded claims to set the median for APC 0651 (Complex
Interstitial Radiation Source Application) in particular (where CPT
code 77778 is assigned). In presentations to the APC Panel at its March
2006 meeting, and in response to the CY 2006 OPPS proposed rule and CY
2007 OPPS/ASC proposed rule, commenters urged us to set the payment
rate for LDR prostate brachytherapy services using only multiple
procedure claims. Specifically for CY 2007, they urged us to 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. 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 to the APC
Panel believed that claims that did not contain both brachytherapy
source and source application codes 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
source application procedure than hospitals that did not report the
separately payable brachytherapy sources.
As a result of those comments, for both CYs 2006 and 2007, we used
multiple procedure claims containing both CPT codes 55859 and 77778 to
determine a median cost for the totality of both services (with both
packaging and bypassing of the other commonly furnished services). We
compared the median calculated from this subset of claims reflecting
the most common clinical scenario to the single bill median costs for
CPT codes 55859 and 77778 as a method of determining whether the total
payment to the hospital for both services furnished to provide LDR
prostate brachytherapy would be reasonable. In both years, we found
that the sum of the single bill medians was reasonably close to the
median cost of both services from multiple claims when they were
treated as a single procedure and the supporting services were either
packaged or bypassed for purposes of calculating the
[[Page 66654]]
median for the combined pair of codes. (We refer readers to the CY 2006
final rule with comment period (70 FR 68596) and the CY 2007 final rule
with comment period (71 FR 68043) for specific discussion of these
findings.) Hence, we concluded that the single bill median costs were
reasonable and, for both the CYs 2006 and CY 2007 OPPS, we based
payment for CPT codes 55859 and 77778 on single procedure claims.
(b) Payment for LDR Prostate Brachytherapy
For the CY 2008 OPPS, we proposed to create a composite APC 8001,
titled ``LDR Prostate Brachytherapy Composite,'' that would provide one
bundled payment for LDR prostate brachytherapy when the hospital bills
both CPT codes 55875 and 77778 as component services provided during
the same hospital encounter. It is shown in Addendum A to this final
rule with comment period as APC 8001 (LDR Prostate Brachytherapy
Composite). As discussed in detail in section VII. of this final rule
with comment period, as we proposed, we are continuing to pay sources
of brachytherapy separately in accordance with the statute.
In the CY 2006 claims used to calculate the proposed CY 2008 median
costs, CPT code 55859 was reported 14,083 times. The proposed rule
median cost for CPT code 55859, calculated from 2,232 single and
``pseudo'' single bills, was approximately $2,329. The CY 2008 proposed
rule median cost for APC 0163 (Level IV Cystourethroscopy and other
Genitourinary Procedures) to which CPT code 55859 was assigned for CY
2006 and to which CPT code 55875 is assigned for CY 2007 was
approximately $2,322. In the set of claims used to calculate the median
cost for APC 0651, to which CPT code 77778 is the only assigned
service, CPT code 77778 was reported 11,850 times. The CY 2008 proposed
rule median cost for APC 0651 (and, therefore, for CPT code 77778)
based on 339 single and ``pseudo'' single procedure bills was
approximately $970.
In examining the claims data used to calculate the median costs for
the proposed rule, we found 9,807 claims on which both CPT code 55859
and CPT code 77778 were billed on the same date of service. These data
suggest that LDR prostate brachytherapy constituted at least 70 percent
of CY 2006 claims for CPT code 55859, with the remainder of claims
representing the insertion of needles or catheters for high dose rate
prostate brachytherapy or unusual clinical situations where the LDR
sources were not applied in the same operative session as the insertion
of the needles or catheters. These data are consistent with our
understanding of current clinical practice for prostate brachytherapy,
and we believe that those multiple claims are correctly coded claims
for this common clinical scenario. Similarly, 83 percent of the claims
for complex interstitial brachytherapy source application CPT code
77778 also included the CPT code for inserting needles or catheters
into the prostate, consistent with our understanding that the vast
majority of cases of complex interstitial brachytherapy source
application procedures are specifically for the treatment of prostate
cancer, rather than other types of cancer.
Using the proposed packaging approach for imaging supervision and
interpretation services and guidance services for CY 2008, we were able
to identify 1,343 claims, 14 percent of all OPPS claims that reported
these two procedures on the same date, that contain both CPT codes
55859 and 77778 on the same date of service and no other separately
paid procedure code. We were not able to use more claims to develop
this composite APC median cost because there are several radiation
therapy planning codes that are commonly reported with CPT codes 55859
and 77778 and that are both separately paid and not on the bypass list
because the amount of their associated packaging exceeds the threshold
for inclusion on the bypass list. A complete discussion of the bypass
list under our CY 2008 packaging policy is provided in section II.A. of
this final rule with comment period.
We packaged the costs of packaged revenue codes and packaged HCPCS
codes into the sum of the costs for CPT codes 55859 and 77778 to derive
a total proposed median cost of approximately $3,127 for the composite
LDR prostate brachytherapy service based upon the 1,343 claims that
contained both CPT codes and no other separately paid procedure codes.
This is reasonably comparable to $3,298, the sum of the CPT median
costs we calculated using the single procedure bills for CPT codes
55859 and 77778 (($2,329 plus $969). As stated in the proposed rule (72
FR 42680), we believe that the difference between the composite APC
median cost based upon those claims that contain both codes and the sum
of the median costs for the APCs to which the two individual CPT codes
map is minimal and may be attributable to efficiencies in furnishing
the services together during a single encounter.
In the proposed rule (72 FR 42681), we indicated our belief that
creation of the composite APC for the payment of LDR prostate
brachytherapy is consistent with the statute and with our desire to use
more claims data for ratesetting, particularly data from correctly
coded claims that reflect typical clinical practice, and to make
payment for larger packages and bundles of services to provide enhanced
incentives for efficiency and cost containment under the OPPS and to
maximize hospital flexibility in managing resources.
Under our proposal, hospitals that furnish LDR prostate
brachytherapy would report CPT codes 55875 and 77778 and the codes for
the applicable brachytherapy sources in the same manner that they
currently report these items and services (in addition to reporting any
other services provided), using the same HCPCS codes and reporting the
same charges. We would require that hospitals report both CPT codes
resulting in the composite APC payment on the same claim when they are
furnished to a single Medicare beneficiary in the same facility on the
same date of service, and we would make any necessary conforming
changes to the billing instructions to ensure that they do not present
an obstacle to correct reporting. We may implement edits to ensure that
hospitals do not submit two separate claims for these two procedures
when furnished on the same date in the same facility. When this
combination of codes is reported, the OCE would assign the composite
APC 8001 and the PRICER would pay based on the payment rate for the
composite APC. The OCE would assign APC 0163 or APC 0651 only when both
codes are not reported on the same claim with the same date of service,
and we would expect this to be the atypical case. The composite APC
would have a status indicator of ``T'' so that payment for other
procedures also assigned to status indicator ``T'' with lower payment
rates would be reduced by 50 percent when furnished on the same date of
service as the composite service, in order to reflect the efficiency
that occurs when multiple procedures are furnished to a Medicare
beneficiary in a single operative session. We would not expect that the
composite APC payment would be frequently reduced under the multiple
procedure reduction policy because we believe that it is unlikely that
a higher paid procedure would be performed on the same date.
We proposed to continue to establish separate payment rates for APC
0651 (to which only CPT code 77778 is assigned) and for APC 0163 (to
which we proposed to continue to assign CPT code 55875). In some cases,
CPT 55875
[[Page 66655]]
may be reported for the insertion of needles or catheters for high dose
rate prostate brachytherapy, and the low dose rate brachytherapy source
application procedure (CPT code 77778) would not be reported. In high
dose rate prostate brachytherapy, the sources are applied temporarily
several times over a few days while the needles or catheters remain in
the prostate, and the needles or catheters are removed only after all
the treatment fractions have been completed. We have also been told by
hospitals that, even when LDR prostate brachytherapy is planned, there
are occasions in which the needles or catheters are inserted in one
facility and the patient is moved to another facility for the
application of the sources. In those cases, we would need to be able to
appropriately pay the hospital that inserted the needles or catheters
before the patient was discharged prior to source application.
Moreover, there are cases in which the needles or catheters are
inserted but it is not possible to proceed to the application of the
sources and, therefore, the hospital would correctly report only CPT
code 55875. Similarly, more than 10 brachytherapy sources can be
applied interstitially (as described by CPT code 77778) to sites other
than the prostate and it is, therefore, necessary to have a separate
payment rate for CPT code 77778. Hence, for CY 2008 we proposed to
continue to pay for CPT code 55875 (the successor to CPT code 55859)
through APC 0163 and to pay for CPT code 77778 through APC 0651 when
the services are individually furnished other than on the same date of
service in the same facility.
Comment: One commenter supported the creation of the composite APC
for LDR Prostate Brachytherapy (APC 8001) but was concerned about the
assignment of status indicator ``T'' to APC 8001. The commenter asked
which codes would be reduced when furnished with the composite as a
result of the assignment of the status indicator ``T.''
Response: We assigned status indicator ``T'' to APC 8001 because
CPT code 55875 is a surgical service that has a status indicator ``T''
in APC 163. The multiple surgical reduction will apply only when other
surgical procedures that have the status indicator of ``T'' are
performed on the same date of service. Payment for the APC with the
highest payment rate with status indicator ``T'' will not be reduced
but payments for other codes on the same claim that also have a status
indicator of ``T'' will be reduced by 50 percent under our standard
multiple procedure reduction policy. Currently, when CPT code 55875 is
reported with another procedure that has a status indicator of ``T,''
payment for the service with the lower payment rate would be reduced by
50 percent. Similarly, when CPT code 55875 is paid as part of composite
APC 8001 and another procedure that has a status indicator of ``T'' is
also reported on the claim, payment for the composite APC or the other
procedure would be reduced by 50 percent, depending on which payment
rate was lower. This is the standard OPPS multiple surgical procedure
payment reduction policy.
As proposed, we are establishing a composite APC, shown in Addendum
A as APC 8001, to provide payment for LDR prostate brachytherapy when
the composite service, billed as CPT codes 55875 and 77778, is
furnished in a single hospital encounter and to base the payment for
the composite APC on the median cost derived from claims that contain
both codes. These two CPT codes are assigned status indicator ``Q'' in
Addendum B to this final rule with comment period to signify their
conditionally packaged status, and their composite APC assignments are
noted in Addendum M. This policy will permit us to base payment on
claims for the most common clinical scenario for interstitial radiation
source application to the prostate. We note that this payment bundle
will also include payment for the commonly associated imaging guidance
services, which will be newly packaged under our CY 2008 packaging
approach. Most importantly, this composite APC payment methodology will
contribute to our goal of providing payment under the OPPS for a larger
bundle of component services provided in a single hospital outpatient
encounter, creating additional hospital incentives for efficiency and
cost containment, while providing hospitals with the most flexibility
to manage their resources. In our final calculation of the median cost
for this composite APC for CY 2008, we were able to use 7,870 claims
that contained both CPT code 77778 and 55859 (the code in effect in
2006) and the median cost on which payment is based is approximately
$3,391. This compares favorably to the proposed rule in which we were
able to us only 1,343 claims containing both codes and calculated a
proposed median cost of approximately $3,127. We believe that the
number of usable claims increased so greatly as the result of the
addition of related procedure codes to the bypass list as a result of
public comments. The CY 2008 composite median is slightly less than
$3,410, the sum of the medians for APCs 163 and 651 ($2,270 + $1,140),
which commenters have told us are unreliable because they are
calculated from single bills although there should never be single
bills for this procedure. Hence, we believe that the median cost for
the composite APC of approximately $3,391, which is calculated from
bills we believe to be correctly coded will result in a reasonable and
appropriate payment rate for this service.
(3) Cardiac Electrophysiologic Evaluation and Ablation Composite APC
(a) Background
During its March 2007 meeting, members of the APC Panel indicated
that the reason we found so few single bills for procedures assigned to
APC 0087 (Cardiac Electrophysiologic Recording/Mapping), specifically
72 of 11,834 or 0.61 percent of all proposed rule CY 2006 claims, is
that most of the services assigned to APCs 0085 (Level II
Electrophysiologic Evaluation), 0086 (Ablate Heart Dysrhythm Focus),
and 0087 are performed in varying combinations with one another.
Therefore, correctly coded claims would most often include multiple
codes for component services that are reported with different CPT codes
and that are now paid separately through different APCs. There would
never be many single bills and those that are reported as single bills
would likely represent atypical cases or incorrectly coded claims.
We examined the combinations of services observed in our claims
data across these three APCs to see whether there was the potential for
handling the data differently so that we could use more claims data to
set the payment rates for these procedures, particularly those services
assigned to APC 0087 where we have had a persistent concern regarding
the limited and reportedly unrepresentative single bills available for
use in calculating the median cost according to our standard OPPS
methodology. We initially developed and examined frequency
distributions of unique combinations of codes on claims which contained
at least one unit of any code assigned to APC 0085, 0086, or 0087 and
then broadened these analysis to any combination of an
electrophysiologic evaluation and ablation code.
Our initial frequency distributions supported the APC Panel
members' description of their experiences. We identified and enumerated
the most commonly appearing unique occurrences (either single
procedures or combinations) of codes for services assigned to status
indicator ``S,'' ``T,'' ``V,'' or ``X'' that contained at least one
[[Page 66656]]
code assigned to APC 0085, 0086, or 0087. There were 7,379 claims in
the top 100 occurrence types. Table 8 shows the 10 most common unique
occurrences from CY 2006 proposed rule claims data available at that
time.
Table 8.--Ten Most Frequently Occurring Unique Occurrences of Cardiac Electrophysiologic Evaluations, Mapping,
and Ablation Procedures and other Separately Payable Services
----------------------------------------------------------------------------------------------------------------
CY 2007 CY 2007
Combination No. Frequency HCPCS code Short descriptor APC SI
----------------------------------------------------------------------------------------------------------------
1................................... 763 93620 Electrophysiology 0085 T
evaluation.
2................................... 509 93609 Map tachycardia, add-on.... 0087 T
93620 Electrophysiology 0085 T
evaluation.
93621 Electrophysiology 0085 T
evaluation.
93623 Stimulation, pacing heart.. 0087 T
93651 Ablate heart dysrhythm 0086 T
focus.
3................................... 398 93609 Map tachycardia, add-on.... 0087 T
93620 Electrophysiology 0085 T
evaluation.
93621 Electrophysiology 0085 T
evaluation.
93651 Ablate heart dysrhythm 0086 T
focus.
4................................... 381 93650 Ablate heart dysrhythm 0086 T
focus.
5................................... 376 93620 Electrophysiology 0085 T
evaluation.
93623 Stimulation, pacing heart.. 0087 T
6................................... 248 93005 Electrocardiogram, tracing. 0099 S
93609 Map tachycardia, add-on.... 0087 T
93620 Electrophysiology 0085 T
evaluation.
93621 Electrophysiology 0085 T
evaluation.
93623 Stimulation, pacing heart.. 0087 T
93651 Ablate heart dysrhythm 0086 T
focus.
7................................... 225 93005 Electrocardiogram, tracing. 0099 S
93609 Map tachycardia, add-on.... 0087 T
93620 Electrophysiology 0085 T
evaluation.
93621 Electrophysiology 0085 T
evaluation.
93651 Ablate heart dysrhythm 0086 T
focus.
8................................... 225 93613 Electrophys map 3d, add-on. 0087 T
93620 Electrophysiology 0085 T
evaluation.
93621 Electrophysiology 0085 T
evaluation.
93651 Ablate heart dysrhythm 0086 T
focus.
9................................... 217 93005 Electrocardiogram, tracing. 0099 S
93620 Electrophysiology 0085 T
evaluation.
10.................................. 185 93613 Electrophys map 3d, add-on. 0087 T
93620 Electrophysiology 0085 T
evaluation.
93621 Electrophysiology 0085 T
evaluation.
93623 Stimulation, pacing heart.. 0087 T
93651 Ablate heart dysrhythm 0086 T
focus.
----------------------------------------------------------------------------------------------------------------
Although the number of claims for each unique occurrence was
modest, we were able to determine that there were certain combinations
of codes that occurred most often together. Based on our review of the
most frequently occurring combinations of codes on claims that also
contained at least one code assigned to APC 0085, 0086 or 0087 and our
clinical review of the codes, we proceeded to study combination claims
that contained at least one code from group A for evaluation services
and at least one code from group B for ablation services reported on
the same date of service on an individual claim, as specified in Table
9 below.
Table 9.--Groups of Cardiac Electrophysiologic Evaluation and Ablation
Procedures on Which We Base the Composite APC
------------------------------------------------------------------------
CY
Codes Used in Combinations: At Least One in HCPCS 2007 CY 2007
Group A and One in Group B code APC SI
------------------------------------------------------------------------
Group A
Electrophysiology evaluation................ 93619 0085 T
Electrophysiology evaluation................ 93620 0085 T
Group B
Ablate heart dysrhythm focus................ 93650 0086 T
Ablate heart dysrhythm focus................ 93651 0086 T
Ablate heart dysrhythm focus................ 93652 0086 T
------------------------------------------------------------------------
When we studied proposed rule claims that contained a code in group
A and also a code in group B, we found that there were 5,118 claims
that met these criteria, and that of these 5,118 claims, 4,552 (89
percent) contained both CPT code 93620 (Comprehensive
electrophysiologic evaluation including insertion and repositioning of
multiple electrode catheters with induction or attempted induction of
arrhythmia; with right atrial pacing and recording, right ventricular
pacing and recording, His bundle recording) from APC 0085 and CPT code
93651 (Intracardiac catheter ablation of arrhythmogenic focus; for
treatment of supraventricular tachycardia by ablation of fast or slow
atrioventricular pathways, accessory atrioventricular connections or
other atrial foci, singly or in combination) from APC 0086 with the
same date of service. Given that CPT code 93651 had a total frequency
of 8,091, this means that more than 55 percent of the claims for CPT
code 93651 also contained CPT
[[Page 66657]]
code 93620. CPT code 93620 had a total frequency of 12,624,
approximately 50 percent higher than the total frequency for CPT code
93651, which is consistent with our expectations because CPT code 93620
describes a diagnostic service and CPT code 93651 is a treatment
service that may be provided based upon the findings of the evaluation
described by CPT code 93620. In addition to the codes for group A and
group B services, the combination claims also contained costs for
packaged services that were reported under revenue codes without HCPCS
codes and under packaged HCPCS codes. As we discuss in considerable
detail above, we lack a methodology that could be used to allocate
these packaged costs to major separately paid procedures in a manner
which gives us confidence that the costs would be attributed correctly.
We have explored and will continue to explore an alternative strategy
that would enable us to use these correctly coded multiple procedure
claims for ratesetting.
In our review of these proposed rule claims, not only did we find a
high number of claims on which there was one code from group A and one
code from group B, but we also found that claims for procedures
assigned to APC 0087 for CY 2007 usually appeared on claims that
contained a code from APC 0085 or APC 0086, or both. The most
frequently appearing CPT codes that were assigned to APC 0087 for CY
2007 were, as shown above, 93609 (Intraventricular and/or intra-atrial
mapping of tachycardia site(s), with catheter manipulation to record
from multiple sites to identify origin of tachycardia (List separately
in addition to code for primary procedure)), 93613 (Intracardiac
electrophysiologic 3-dimensional mapping (List separately in addition
to code for primary procedure)), 93621 (Comprehensive
electrophysiologic evaluation including insertion and repositioning of
multiple electrode catheters with induction or attempted induction of
arrhythmia; with left atrial pacing and recording from coronary sinus
or left atrium (List separately in addition to code for primary
procedure)), 93622 (Comprehensive electrophysiologic evaluation
including insertion and repositioning of multiple electrode catheters
with induction or attempted induction of arrhythmia; with left
ventricular pacing and recording (List separately in addition to code
for primary procedure)), and 93623 (Programmed simulation and pacing
after intravenous drug infusion (List separately in addition to code
for primary procedure)). These codes are all CPT add-on codes that CPT
indicates are to be reported in addition to the code for the primary
procedure. Our clinical review of the services described by these five
CPT codes determined that they are supportive dependent services that
are provided most often as supplemental to procedures assigned to APCs
0085 and 0086. The procedures in APCs 0085 and 0086 can be performed
without these supportive add-on procedures, but these dependent
services cannot be done except as a supplement to another
electrophysiologic procedure. Therefore, we proposed to unconditionally
package all of these five CPT codes under the grouping of
intraoperative services for the CY 2008 OPPS. We discuss the packaging
of intraoperative services in general, including these services, in
section II.A.4.c.(3) above.
However, packaging these supportive ancillary services that are so
often reported with the cardiac electrophysiologic evaluation and
ablation services did not, by itself, enable us to use many more claims
because, as we noted previously, the claims on which these codes most
commonly appeared typically also contained at least one separately paid
code from APC 0085 and one code from APC 0086. Although the most common
combination of codes from APCs 0085 and 0086 was the pair of CPT codes
93620 and 93651, there are numerous other combinations of services from
APCs 0085 and 0086 that were performed and, while not as frequent,
these combinations were also reflected in the multiple claims.
In order to use more claims and adequately reflect the varied,
common combinations of electrophysiologic evaluation and ablation CPT
codes, we calculated a composite median cost from all claims containing
at least one code from group A and at least one code from group B as if
they were a single service. We selected multiple procedure claims that
contained at least one code in group A and one code in group B on the
same date of service and calculated a median cost from the total costs
on these claims. Some claims had more than one code from each group.
Although the claim was required to contain at least one code from each
group to be included, the claim could also contain any number of codes
from either group and any number of units of those codes. In addition,
the costs of the five supportive intraoperative services previously
assigned to APC 0087 that we identify above were packaged, as well as
the costs of the other items and services proposed to be packaged for
the CY 2008 OPPS. This selection process yielded 5,118 claims to use
for the calculation. The proposed composite median cost for these
claims using the CY 2008 proposed rule data was approximately $8,529.
We believe that this cost is attributable largely to the 4,552 claims
that contain one unit each of CPT code 93620 and CPT code 93651 (and
some unknown numbers and combinations of packaged services). In
comparison, the sum of the CY 2008 proposed rule CPT code median costs
for CPT code 93620 (which is $3,111) and CPT code 93651 (which is
$5,644) is approximately $8,756. If the 50 percent multiple procedure
discount is applied to the CPT code median cost for the lower cost
procedure based on its assignment to an APC with a ``T'' status, the
adjusted sum of the median costs is $7,200 ($5,644 + $1,556). These
medians were calculated using only claims that contain correct devices
and do not contain token charges or the ``FB'' modifier. We believe the
significant positive difference between the composite and discounted
costs still reflects efficiencies, as the sum of the discounted median
costs does not take into account the cost of other procedures also
provided that are assigned to APCs 0085 and 0086, while the composite
median cost of $8,528.83 does, to some extent, reflect the cost of
other multiple procedures in APCs 0085 and 0086 that were also reported
on the claims used to develop the composite median cost. In addition,
these two calculations are based upon two different sets of claims,
single procedure claims in one case (which do not represent the way the
service is typically furnished) and the specified subset of clinically
common combination claims in the second case. Moreover, while the 50
percent multiple procedure reduction is our best aggregate estimate of
the overall degree of efficiency applicable to multiple surgeries, it
may or may not be specifically appropriate to this particular
combination of procedures.
By selecting the multiple procedure claims that contained at least
one code in each group, we were able to use many more claims than were
available to establish the individual APC medians. The percents by CPT
code for the composite configuration in Table 24 of the proposed rule
(72 FR 42684) represented the sum of the frequency of single bills used
to set the medians for APCs 0085 and 0086 with packaging of the five
intraoperative services and the frequency of multiple bills used to set
the medians for the composite claims containing at least one code from
each group and with packaging of the costs
[[Page 66658]]
of the five intraoperative services, divided by the total frequency of
each CPT code.
Moreover, by packaging CPT codes 93609, 93613, 93621, 93622, and
93623, we were able to use many more of the claims for these codes from
the most common clinical scenarios than would otherwise be possible if
the supportive intraoperative services were separately paid. Wherever
any of these codes appears on a claim that could be used for median
setting, the cost data for these codes are packaged in the calculation
of the median cost for the separately paid services on the claim.
(b) Payment for Cardiac Electrophysiologic Evaluation and Ablation
In view of our findings with regard to how often the codes in
groups A and B appear together on the same claim, we proposed to
establish one composite APC, shown in Addendum A of the proposed rule
as APC 8000 (Cardiac Electrophysiologic Evaluation and Ablation
Composite), for CY 2008 that would pay for a composite service made up
of any number of services in groups A and B when at least one code from
group A and at least one code from group B appear on the same claim
with the same date of service. The five CPT codes involved in this
composite APC are assigned to status indicator ``Q'' in Addendum B to
the proposed rule to identify their conditionally packaged status, and
their composite APC assignments were identified in Addendum M of the
proposed rule. We proposed to use the composite median cost of
approximately $8,529 as the basis for establishing the relative weight
for this newly created APC for the composite electrophysiology
evaluation and ablation service. Under this composite APC, unlike most
other APCs, we proposed to make a single payment for all services
reported in groups A and B. We proposed that hospitals would continue
to code using CPT codes to report these services and that the OCE would
recognize when the criteria for payment of the composite APC are met
and would assign the composite APC instead of the single procedure APCs
as currently occurs. The PRICER would make a single payment for the
composite APC that would encompass the program payment for the code in
group A, the code in group B, and any other codes reported in groups A
or B, as well as the packaged services furnished on the same date of
service. The proposed composite APC would have a status indicator of
``T'' so that payment for other procedures also assigned to status
indicator ``T'' with lower payment rates would be reduced by 50 percent
when furnished on the same date of service as the composite service, in
order to reflect the efficiency that occurs when multiple procedures
are furnished to a Medicare beneficiary in a single operative session.
We would not expect that the proposed composite APC payment would be
commonly reduced because we believe that it is unlikely that a higher
paid procedure would be performed on the same date. We proposed to
continue to pay separately for other separately paid services that are
not reported under the codes in groups A and B (such as chest x-rays
and electrocardiograms).
Moreover, where a service in group A is furnished on a date of
service that is different from the date of service for a code in group
B for the same beneficiary, we proposed that payments would be made
under the single procedure APCs and the composite APC would not apply.
Given our CY 2008 proposal to unconditionally package payment for five
cardiac electrophysiologic CPT codes as members of the category of
intraoperative services that were previously assigned to APCs 0085 and
0087, we also proposed to reconfigure APCs 0084 through 0087, where
many of the cardiac electrophysiologic procedures that will be
separately paid when they are not paid according to the composite APC
are assigned. Specifically, we proposed to discontinue APC 0087, and
reconfigure APCs 0084, 0085, and 0086, with proposed titles and median
costs of Level I Electrophysiologic Procedures (APC 0084) at
approximately $603; Level II Electrophysiologic Procedures (APC 0085)
at approximately $2,976; and Level III Electrophysiologic Procedures
(APC 0086) at approximately $5,842, respectively. We refer readers to
section IV.A.2. of this his final rule with comment period rule for a
discussion of calculation of median costs for device-dependent APCs. We
believe this reconfiguration improved the clinical and resource
homogeneity of these APCs which would provide payment for cardiac
electrophysiologic procedures that would be individually paid when they
do not meet the criteria for payment of the composite APC.
We believe that creation of the proposed composite APC for cardiac
electrophysiology evaluation and ablation services is the most
efficient and effective way to use the claims data for the majority of
these services and best represents the hospital resources associated
with performing the common combinations of these services that are
clinically typical. We believe that the proposed ratesetting
methodology results in an appropriate median cost for the composite
service when at least one evaluation service in group A is furnished on
the same date as at least one ablation service in group B. This
approach creates incentives for efficiency by providing a single
payment for a larger bundle of major procedures when they are performed
together, in contrast to continued separate payment for each of the
individual procedures. We expect to develop additional composite APCs
in the future as we learn more about major currently separately paid
services that are commonly furnished together during the same hospital
outpatient encounter.
We did not receive any public comments specific to the creation of
the composite APC for cardiac electrophysiology evaluation and ablation
other than those included in the general discussion of composite APCs
above. Therefore, we are finalizing the creation of this APC as
proposed. For this final rule with comment period, we recalculated the
median cost of the APC as proposed. We were able to use 5,596 claims
that met the criteria of having at least one code in group A and one
code in group B, which had correct device codes, no token charges for
devices and no FB modifiers on the claims. Using these 5,596 correctly
coded claims from the final rule data, we calculated a median cost from
the final rule data of approximately $8,438. We note that while the
number of usable claims for the final rule date increased to 5,596 from
the 5,118 claims used in the proposed rule, the median cost declined
slightly (approximately 1 percent) to approximately $8,438 from the
$8,529 median cost calculated from proposed rule data. However, we
believe that the median cost for this composite APC is a valid
reflection of the estimated relative cost of these services when
furnished in combination with one another.
After consideration of the public comments we received on the
proposed composite APCs for LDR Prostate Brachytherapy and Cardiac
Electrophysiology Evaluation and Ablation, we are finalizing our
proposed policy regarding these composite APCs without modification.
In conclusion, we are finalizing our proposed packaging approach
with the modifications discussed above for the CY 2008 OPPS. Table 10
in this final rule with comment period displays the list of packaged
services in the categories of guidance, image processing,
intraoperative services, radiopharmaceuticals, contrast media, imaging
supervision and interpretation,
[[Page 66659]]
and observation services. Codes in composite APCs, including the two
extended assessment and management APCs, are displayed in Addendum M.
In Table 10, HCPCS codes with status indicator ``N'' are always
packaged. HCPCS codes with status indicator ``Q'' are conditionally
packaged. Codes with status indicator ``Q'' that are for imaging
supervision and interpretation are packaged only when reported on the
same claim on the same day as a procedure with status indicator ``T''
and are identified as ``T-packaged'' in the sixth column. Codes that
are packaged when they are reported on the same claim with a code with
status indicator ``S,'' ``T,'' ``V,'' or ``X'' on the same day are
identified as ``STVX-packaged'' in the sixth column.
Table 10.--CY 2008 Packaged HCPCS Codes Included in Seven Packaging Categories
--------------------------------------------------------------------------------------------------------------------------------------------------------
Final ``STVX-
CY CY CY packaged'' Final CY
2008 HCPCS code Short descriptor 2007 2007 2008 or ``T- 2008 APC Category
SI APC SI packaged''
(1) (2).............................. (3) (4) (5) (6) (7) (8)
--------------------------------------------------------------------------------------------------------------------------------------------------------
19295..................... Place breast clip, percut........ S 0657 N n/a n/a Guidance
20975..................... Electrical bone stimulation...... X 0340 N n/a n/a Intraoperative.
20985..................... Cptr-asst dir ms px.............. n/a n/a N n/a n/a Guidance.
20986..................... Cptr-asst dir ms px io img....... n/a n/a N n/a n/a Guidance.
20987..................... Cptr-asst dir ms px pre img...... n/a n/a N n/a n/a Guidance.
31620..................... Endobronchial us add-on.......... S 0670 N n/a n/a Intraoperative.
37250..................... Iv us first vessel add-on........ S 0416 N n/a n/a Intraoperative.
37251..................... Iv us each add vessel add-on..... S 0416 N n/a n/a Intraoperative.
58110..................... Bx done w/colposcopy add-on...... T 0188 N n/a n/a Intraoperative.
61795..................... Brain surgery using computer..... S 0302 N n/a n/a Guidance.
62160..................... Neuroendoscopy add-on............ T 0122 N n/a n/a Guidance.
70010..................... Contrast x-ray of brain.......... S 0274 Q T 0274 Imaging S&I.
70015..................... Contrast x-ray of brain.......... S 0274 Q T 0274 Imaging S&I.
70170..................... X-ray exam of tear duct.......... X 0264 Q T 0317 Imaging S&I.
70332..................... X-ray exam of jaw joint.......... S 0275 Q T 0275 Imaging S&I.
70373..................... Contrast x-ray of larynx......... X 0263 Q T 0263 Imaging S&I.
70390..................... X-ray exam of salivary duct...... X 0263 Q T 0263 Imaging S&I.
71040..................... Contrast x-ray of bronchi........ X 0263 Q T 0263 Imaging S&I.
71060..................... Contrast x-ray of bronchi........ X 0263 Q T 0317 Imaging S&I.
71090..................... X-ray & pacemaker insertion...... X 0272 N n/a n/a Imaging S&I.
72240..................... Contrast x-ray of neck spine..... S 0274 Q T 0274 Imaging S&I.
72255..................... Contrast x-ray, thorax spine..... S 0274 Q T 0274 Imaging S&I.
72265..................... Contrast x-ray, lower spine...... S 0274 Q T 0274 Imaging S&I.
72270..................... Contrast x-ray, spine............ S 0274 Q T 0274 Imaging S&I.
72275..................... Epidurography.................... S 0274 N n/a n/a Imaging S&I.
72285..................... X-ray c/t spine disk............. S 0388 Q T 0388 Imaging S&I.
72291..................... Perq vertebroplasty, fluor....... S 0274 N n/a n/a Imaging S&I.
72292..................... Perq vertebroplasty, ct.......... S 0274 N n/a n/a Imaging S&I.
72295..................... X-ray of lower spine disk........ S 0388 Q T 0388 Imaging S&I.
73040..................... Contrast x-ray of shoulder....... S 0275 Q T 0275 Imaging S&I.
73085..................... Contrast x-ray of elbow.......... S 0275 Q T 0275 Imaging S&I.
73115..................... Contrast x-ray of wrist.......... S 0275 Q T 0275 Imaging S&I.
73525..................... Contrast x-ray of hip............ S 0275 Q T 0275 Imaging S&I.
73530..................... X-ray exam of hip................ X 0261 N n/a n/a Intraoperative.
73542..................... X-ray exam, sacroiliac joint..... S 0275 Q T 0275 Imaging S&I.
73580..................... Contrast x-ray of knee joint..... S 0275 Q T 0275 Imaging S&I.
73615..................... Contrast x-ray of ankle.......... S 0275 Q T 0275 Imaging S&I.
74190..................... X-ray exam of peritoneum......... S 0264 Q T 0317 Imaging S&I.
74235..................... Remove esophagus obstruction..... S 0257 N n/a n/a Imaging S&I.
74300..................... X-ray bile ducts/pancreas........ X 0263 N n/a n/a Intraoperative.
74301..................... X-rays at surgery add-on......... X 0263 N n/a n/a Intraoperative.
74305..................... X-ray bile ducts/pancreas........ X 0263 N n/a n/a Imaging S&I.
74320..................... Contrast x-ray of bile ducts..... X 0264 Q T 0317 Imaging S&I.
74327..................... X-ray bile stone removal......... S 0296 N n/a n/a Imaging S&I.
74328..................... X-ray bile duct endoscopy........ N n/a N n/a n/a Imaging S&I.
74329..................... X-ray for pancreas endoscopy..... N n/a N n/a n/a Imaging S&I.
74330..................... X-ray bile/panc endoscopy........ N n/a N n/a n/a Imaging S&I.
74340..................... X-ray guide for GI tube.......... X 0272 N n/a n/a Imaging S&I.
74355..................... X-ray guide, intestinal tube..... X 0263 N n/a n/a Imaging S&I.
74360..................... X-ray guide, GI dilation......... S 0257 N n/a n/a Imaging S&I.
74363..................... X-ray, bile duct dilation........ S 0297 N n/a n/a Imaging S&I.
74425..................... Contrst x-ray, urinary tract..... S 0278 Q T 0278 Imaging S&I.
74430..................... Contrast x-ray, bladder.......... S 0278 Q T 0278 Imaging S&I.
74440..................... X-ray, male genital tract........ S 0278 Q T 0278 Imaging S&I.
74445..................... X-ray exam of penis.............. S 0278 Q T 0278 Imaging S&I.
74450..................... X-ray, urethra/bladder........... S 0278 Q T 0278 Imaging S&I.
74455..................... X-ray, urethra/bladder........... S 0278 Q T 0278 Imaging S&I.
74470..................... X-ray exam of kidney lesion...... X 0263 Q T 0263 Imaging S&I.
74475..................... X-ray control, cath insert....... S 0297 Q T 0317 Imaging S&I.
[[Page 66660]]
74480..................... X-ray control, cath insert....... S 0296 Q T 0317 Imaging S&I.
74485..................... X-ray guide, GU dilation......... S 0296 Q T 0317 Imaging S&I.
74740..................... X-ray, female genital tract...... X 0264 Q T 0263 Imaging S&I.
74742..................... X-ray, fallopian tube............ X 0264 N n/a n/a Imaging S&I.
75600..................... Contrast x-ray exam of aorta..... S 0280 Q T 0279 Imaging S&I.
75605..................... Contrast x-ray exam of aorta..... S 0280 Q T 0279 Imaging S&I.
75625..................... Contrast x-ray exam of aorta..... S 0280 Q T 0279 Imaging S&I.
75630..................... X-ray aorta, leg arteries........ S 0280 Q T 0279 Imaging S&I.
75635..................... Ct angio abdominal arteries...... S 0662 Q T 0662 Imaging S&I.
75650..................... Artery x-rays, head & neck....... S 0280 Q T 0280 Imaging S&I.
75658..................... Artery x-rays, arm............... S 0279 Q T 0279 Imaging S&I.
75660..................... Artery x-rays, head & neck....... S 0668 Q T 0280 Imaging S&I.
75662..................... Artery x-rays, head & neck....... S 0280 Q T 0280 Imaging S&I.
75665..................... Artery x-rays, head & neck....... S 0280 Q T 0279 Imaging S&I.
75671..................... Artery x-rays, head & neck....... S 0280 Q T 0280 Imaging S&I.
75676..................... Artery x-rays, neck.............. S 0280 Q T 0279 Imaging S&I.
75680..................... Artery x-rays, neck.............. S 0280 Q T 0279 Imaging S&I.
75685..................... Artery x-rays, spine............. S 0280 Q T 0279 Imaging S&I.
75705..................... Artery x-rays, spine............. S 0668 Q T 0279 Imaging S&I.
75710..................... Artery x-rays, arm/leg........... S 0280 Q T 0279 Imaging S&I.
75716..................... Artery x-rays, arms/legs......... S 0280 Q T 0279 Imaging S&I.
75722..................... Artery x-rays, kidney............ S 0280 Q T 0279 Imaging S&I.
75724..................... Artery x-rays, kidneys........... S 0280 Q T 0279 Imaging S&I.
75726..................... Artery x-rays, abdomen........... S 0280 Q T 0279 Imaging S&I.
75731..................... Artery x-rays, adrenal gland..... S 0280 Q T 0279 Imaging S&I.
75733..................... Artery x-rays, adrenals.......... S 0668 Q T 0279 Imaging S&I.
75736..................... Artery x-rays, pelvis............ S 0280 Q T 0279 Imaging S&I.
75741..................... Artery x-rays, lung.............. S 0279 Q T 0279 Imaging S&I.
75743..................... Artery x-rays, lungs............. S 0280 Q T 0279 Imaging S&I.
75746..................... Artery x-rays, lung.............. S 0279 Q T 0668 Imaging S&I.
75756..................... Artery x-rays, chest............. S 0279 Q T 0668 Imaging S&I.
75774..................... Artery x-ray, each vessel........ S 0279 N n/a n/a Imaging S&I.
75790..................... Visualize A-V shunt.............. S 0279 Q T 0668 Imaging S&I.
75801..................... Lymph vessel x-ray, arm/leg...... X 0264 Q T 0317 Imaging S&I.
75803..................... Lymph vessel x-ray, arms/legs.... X 0264 Q T 0317 Imaging S&I.
75805..................... Lymph vessel x-ray, trunk........ X 0264 Q T 0317 Imaging S&I.
75807..................... Lymph vessel x-ray, trunk........ X 0264 Q T 0317 Imaging S&I.
75809..................... Nonvascular shunt, x-ray......... X 0263 Q T 0263 Imaging S&I.
75810..................... Vein x-ray, spleen/liver......... S 0279 Q T 0279 Imaging S&I.
75820..................... Vein x-ray, arm/leg.............. S 0668 Q T 0668 Imaging S&I.
75822..................... Vein x-ray, arms/legs............ S 0668 Q T 0668 Imaging S&I.
75825..................... Vein x-ray, trunk................ S 0279 Q T 0279 Imaging S&I.
75827..................... Vein x-ray, chest................ S 0279 Q T 0668 Imaging S&I.
75831..................... Vein x-ray, kidney............... S 0279 Q T 0279 Imaging S&I.
75833..................... Vein x-ray, kidneys.............. S 0279 Q T 0279 Imaging S&I.
75840..................... Vein x-ray, adrenal gland........ S 0280 Q T 0279 Imaging S&I.
75842..................... Vein x-ray, adrenal glands....... S 0280 Q T 0279 Imaging S&I.
75860..................... Vein x-ray, neck................. S 0668 Q T 0668 Imaging S&I.
75870..................... Vein x-ray, skull................ S 0668 Q T 0668 Imaging S&I.
75872..................... Vein x-ray, skull................ S 0279 Q T 0668 Imaging S&I.
75880..................... Vein x-ray, eye socket........... S 0668 Q T 0668 Imaging S&I.
75885..................... Vein x-ray, liver................ S 0280 Q T 0279 Imaging S&I.
75887..................... Vein x-ray, liver................ S 0279 Q T 0668 Imaging S&I.
75889..................... Vein x-ray, liver................ S 0280 Q T 0279 Imaging S&I.
75891..................... Vein x-ray, liver................ S 0279 Q T 0279 Imaging S&I.
75893..................... Venous sampling by catheter...... Q 0668 Q T 0279 Imaging S&I.
75894..................... X-rays, transcath therapy........ S 0298 N n/a n/a Imaging S&I.
75896..................... X-rays, transcath therapy........ S 0263 N n/a n/a Imaging S&I.
75898..................... Follow-up angiography............ X 0263 Q STVX 0263 Intraoperative.
75901..................... Remove cva device obstruct....... X 0263 N n/a n/a Imaging S&I.
75902..................... Remove cva lumen obstruct........ X 0263 N n/a n/a Imaging S&I.
75940..................... X-ray placement, vein filter..... S 0298 N n/a n/a Imaging S&I.
75945..................... Intravascular us................. S 0267 Q T 0267 Imaging S&I.
75946..................... Intravascular us add-on.......... S 0266 N n/a n/a Imaging S&I.
75960..................... Transcath iv stent rs&i.......... S 0668 N n/a n/a Imaging S&I.
75961..................... Retrieval, broken catheter....... S 0668 N n/a n/a Imaging S&I.
75962..................... Repair arterial blockage......... S 0668 Q T 0083 Imaging S&I.
[[Page 66661]]
75964..................... Repair artery blockage, each..... S 0668 N n/a n/a Imaging S&I.
75966..................... Repair arterial blockage......... S 0668 Q T 0083 Imaging S&I.
75968..................... Repair artery blockage, each..... S 0668 N n/a n/a Imaging S&I.
75970..................... Vascular biopsy.................. S 0668 N n/a n/a Imaging S&I.
75978..................... Repair venous blockage........... S 0668 Q T 0083 Imaging S&I.
75980..................... Contrast xray exam bile duct..... S 0297 N n/a n/a Imaging S&I.
75982..................... Contrast xray exam bile duct..... S 0297 N n/a n/a Imaging S&I.
75984..................... Xray control catheter change..... X 0263 N n/a n/a Imaging S&I.
75989..................... Abscess drainage under x-ray..... N ...... N n/a n/a Imaging S&I.
75992..................... Atherectomy, x-ray exam.......... S 0668 N n/a n/a Imaging S&I.
75993..................... Atherectomy, x-ray exam.......... S 0668 N n/a n/a Imaging S&I.
75994..................... Atherectomy, x-ray exam.......... S 0668 N n/a n/a Imaging S&I.
75995..................... Atherectomy, x-ray exam.......... S 0668 N n/a n/a Imaging S&I.
75996..................... Atherectomy, x-ray exam.......... S 0668 N n/a n/a Imaging S&I.
76000..................... Fluoroscope examination.......... X 0272 Q STVX 0272 Guidance.
76001..................... Fluoroscope exam, extensive...... N n/a N n/a n/a Guidance.
76080..................... X-ray exam of fistula............ X 0263 Q T 0263 Imaging S&I.
76125..................... Cine/video x-rays add-on......... X 0260 N n/a n/a Image Processing.
76350..................... Special x-ray contrast study..... N n/a N n/a n/a Image Processing.
76376..................... 3d render w/o postprocess........ X 0340 N n/a n/a Image Processing.
76377..................... 3d rendering w/postprocess....... S 0282 N n/a n/a Image Processing.
76930..................... Echo guide, cardiocentesis....... S 0268 N n/a n/a Guidance.
76932..................... Echo guide for heart biopsy...... S 0309 N n/a n/a Guidance.
76936..................... Echo guide for artery repair..... S 0309 N n/a n/a Guidance.
76937..................... Us guide, vascular access........ N n/a N n/a n/a Guidance.
76940..................... Us guide, tissue ablation........ S 0268 N n/a n/a Guidance.
76941..................... Echo guide for transfusion....... S 0268 N n/a n/a Guidance.
76942..................... Echo guide for biopsy............ S 0268 N n/a n/a Guidance.
76945..................... Echo guide, villus sampling...... S 0268 N n/a n/a Guidance.
76946..................... Echo guide for amniocentesis..... S 0268 N n/a n/a Guidance.
76948..................... Echo guide, ova aspiration....... S 0309 N n/a n/a Guidance.
76950..................... Echo guidance radiotherapy....... S 0268 N n/a n/a Guidance.
76965..................... Echo guidance radiotherapy....... S 0308 N n/a n/a Guidance.
76975..................... GI endoscopic ultrasound......... S 0266 Q T 0267 Imaging S&I.
76998..................... Us guide, intraop................ S 0266 N n/a n/a Guidance.
77001..................... Fluoro guide for vein device..... N n/a N n/a n/a Guidance.
77002..................... Needle localization by xray...... N n/a N n/a n/a Guidance.
77003..................... Fluoroguide for spine inject..... N n/a N n/a n/a Guidance.
77011..................... Ct scan for localization......... S 0283 N n/a n/a Guidance.
77012..................... Ct scan for needle biopsy........ S 0283 N n/a n/a Guidance.
77013..................... Ct guide for tissue ablation..... S 0333 N n/a n/a Guidance.
77014..................... Ct scan for therapy guide........ S 0282 N n/a n/a Guidance.
77021..................... Mr guidance for needle place..... S 0335 N n/a n/a Guidance.
77022..................... Mri for tissue ablation.......... S 0335 N n/a n/a Guidance.
77031..................... Stereotact guide for brst bx..... X 0264 N n/a n/a Guidance.
77032..................... Guidance for needle, breast...... X 0283 N n/a n/a Guidance.
77053..................... X-ray of mammary duct............ X 0263 Q T 0263 Imaging S&I.
77054..................... X-ray of mammary ducts........... X 0263 Q T 0263 Imaging S&I.
77417..................... Radiology port film(s)........... X 0260 N n/a n/a Guidance.
77421..................... Stereoscopic x-ray guidance...... S 0257 N n/a n/a Guidance.
78020..................... Thyroid met uptake............... S 0399 N n/a n/a Intraoperative.
78478..................... Heart wall motion add-on......... S 0399 N n/a n/a Intraoperative.
78480..................... Heart function add-on............ S 0399 N n/a n/a Intraoperative.
78496..................... Heart first pass add-on1......... S 0399 N n/a n/a Intraoperative.
92547..................... Supplemental electrical test..... X 0363 N n/a n/a Intraoperative.
92978..................... Intravasc us, heart add-on....... S 0670 N n/a n/a Intraoperative.
92979..................... Intravasc us, heart add-on....... S 0416 N n/a n/a Intraoperative.
93320..................... Doppler echo exam, heart......... S 0697 N n/a n/a Intraoperative.
93321..................... Doppler echo exam, heart......... S 0697 N n/a n/a Intraoperative.
93325..................... Doppler color flow add-on........ S 0697 N ........... n/a Image Processing.
93555..................... Imaging, cardiac cath............ N n/a N n/a n/a Imaging S&I.
93556..................... Imaging, cardiac cath............ N n/a N n/a n/a Imaging S&I.
93571..................... Heart flow reserve measure....... S 0670 N n/a n/a Intraoperative.
93572..................... Heart flow reserve measure....... S 0416 N n/a n/a Intraoperative.
93609..................... Map tachycardia, add-on.......... T 0087 N n/a n/a Intraoperative.
93613..................... Electrophys map 3d, add-on....... T 0087 N n/a n/a Image Processing.
93621..................... Electrophysiology evaluation..... T 0085 N n/a n/a Intraoperative.
[[Page 66662]]
93622..................... Electrophysiology evaluation..... T 0085 N n/a n/a Intraoperative.
93623..................... Stimulation, pacing heart........ T 0087 N n/a n/a Intraoperative.
93631..................... Heart pacing, mapping............ T 0087 N n/a n/a Intraoperative.
93640..................... Evaluation heart device.......... N n/a N n/a n/a Intraoperative.
93641..................... Electrophysiology evaluation..... N n/a N n/a n/a Intraoperative.
93662..................... Intracardiac ecg (ice)........... S 0670 N n/a n/a Intraoperative.
95829..................... Surgery electrocorticogram....... S 0214 N n/a n/a Intraoperative.
95873..................... Guide nerv destr, elec stim...... S 0215 N n/a n/a Guidance.
95874..................... Guide nerv destr, needle emg..... S 0215 N n/a n/a Guidance.
95920..................... Intraop nerve test add-on........ S 0216 N n/a n/a Intraoperative.
95955..................... EEG during surgery............... S 0213 N n/a n/a Intraoperative.
95957..................... EEG digital analysis............. S 0214 N n/a n/a Image Processing.
95980..................... Io anal gast n-stim init......... n/a n/a N n/a n/a Intraoperative.
96020..................... Functional brain mapping......... X 0373 N n/a n/a Intraoperative.
0126T..................... Chd risk imt study............... N n/a Q STVX 0340 Intraoperative.
0159T..................... Cad breast MRI................... N n/a N n/a n/a Image Processing.
0173T..................... Iop monit io pressure............ N n/a N n/a n/a Intraoperative.
0174T..................... Cad cxr remote................... N n/a N n/a n/a Image Processing.
0175T..................... Cad cxr with interp.............. N n/a N n/a n/a Image Processing.
A4641..................... Radiopharm dx agent noc.......... N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A4642..................... In111 satumomab.................. H 0704 N n/a n/a Diagnostic Radiopharmaceutical.
A9500..................... Tc99m sestamibi.................. H 1600 N n/a n/a Diagnostic Radiopharmaceutical.
A9501..................... Technetium TC-99m teboroxime..... n/a n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9502..................... Tc99m tetrofosmin................ H 0705 N n/a n/a Diagnostic Radiopharmaceutical.
A9503..................... Tc99m medronate.................. N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9504..................... Tc99m apcitide................... N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9505..................... TL201 thallium................... H 1603 N n/a n/a Diagnostic Radiopharmaceutical.
A9507..................... In111 capromab................... H 1604 N n/a n/a Diagnostic Radiopharmaceutical.
A9508..................... I131 iodobenguate, dx............ H 1045 N n/a n/a Diagnostic Radiopharmaceutical.
A9509..................... Iodine I-123 sod iodide mil...... n/a n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9510..................... Tc99m disofenin.................. N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9512..................... Tc99m pertechnetate.............. N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9516..................... I123 iodide cap, dx.............. H 9148 N n/a n/a Diagnostic Radiopharmaceutical.
A9521..................... Tc99m exametazime................ H 1096 N n/a n/a Diagnostic Radiopharmaceutical.
A9524..................... I131 serum albumin, dx........... H 9100 N n/a n/a Diagnostic Radiopharmaceutical.
A9526..................... Nitrogen N-13 ammonia............ H 0737 N n/a n/a Diagnostic Radiopharmaceutical.
A9528..................... Iodine I-131 iodide cap, dx...... H 1088 N n/a n/a Diagnostic Radiopharmaceutical.
A9529..................... I131 iodide sol, dx.............. N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9531..................... I131 max 100uCi.................. N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9532..................... I125 serum albumin, dx........... N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9536..................... Tc99m depreotide................. H 0739 N n/a n/a Diagnostic Radiopharmaceutical.
A9537..................... Tc99m mebrofenin................. N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9538..................... Tc99m pyrophosphate.............. N n/a N n/a n/a Diagnostic Radiopharmaceutical.
[[Page 66663]]
A9539..................... Tc99m pentetate.................. H 0722 N n/a n/a Diagnostic Radiopharmaceutical.
A9540..................... Tc99m MAA........................ N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9541..................... Tc99m sulfur colloid............. N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9542..................... In111 ibritumomab, dx............ H 1642 N n/a n/a Diagnostic Radiopharmaceutical.
A9544..................... I131 tositumomab, dx............. H 1644 N n/a n/a Diagnostic Radiopharmaceutical.
A9546..................... Co57/58.......................... H 0723 N n/a n/a Diagnostic Radiopharmaceutical.
A9547..................... In111 oxyquinoline............... H 1646 N n/a n/a Diagnostic Radiopharmaceutical.
A9548..................... In111 pentetate.................. H 1647 N n/a n/a Diagnostic Radiopharmaceutical.
A9550..................... Tc99m gluceptate................. H 0740 N n/a n/a Diagnostic Radiopharmaceutical.
A9551..................... Tc99m succimer................... H 1650 N n/a n/a Diagnostic Radiopharmaceutical.
A9552..................... F18 fdg.......................... H 1651 N n/a n/a Diagnostic Radiopharmaceutical.
A9553..................... Cr51 chromate.................... H 0741 N n/a n/a Diagnostic Radiopharmaceutical.
A9554..................... I125 iothalamate, dx............. N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9555..................... Rb82 rubidium.................... H 1654 N n/a n/a Diagnostic Radiopharmaceutical.
A9556..................... Ga67 gallium..................... H 1671 N n/a n/a Diagnostic Radiopharmaceutical.
A9557..................... Tc99m bicisate................... H 1672 N n/a n/a Diagnostic Radiopharmaceutical.
A9558..................... Xe133 xenon 10mci................ N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9559..................... Co57 cyano....................... H 0724 N n/a n/a Diagnostic Radiopharmaceutical.
A9560..................... Tc99m labeled rbc................ H 0742 N n/a n/a Diagnostic Radiopharmaceutical.
A9561..................... Tc99m oxidronate................. N n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9562..................... Tc99m mertiatide................. H 0743 N n/a n/a Diagnostic Radiopharmaceutical.
A9566..................... Tc99m fanolesomab................ H 1678 N n/a n/a Diagnostic Radiopharmaceutical.
A9567..................... Technetium TC-99m aerosol........ H 0829 N n/a n/a Diagnostic Radiopharmaceutical.
A9568..................... Tc99m arcitumomab................ H 1648 N n/a n/a Diagnostic Radiopharmaceutical.
A9569..................... Technetium TC-99m auto WBC....... n/a n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9570..................... Indium In-111 auto WBC........... n/a n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9571..................... Indium In-111 auto platelet...... n/a n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9572..................... Indium In-111 pentetreotide...... n/a n/a N n/a n/a Diagnostic Radiopharmaceutical.
A9576..................... Inj prohance multipack........... n/a n/a N n/a n/a Contrast Agent.
A9577..................... Inj multihance................... n/a n/a N n/a n/a Contrast Agent.
A9578..................... Inj multihance multipack......... n/a n/a N n/a n/a Contrast Agent.
A9579..................... Gad-base MR contrast NOS, 1ml.... n/a n/a N n/a n/a Contrast Agent.
G0268..................... Removal of impacted wax md....... X 0340 N n/a n/a Intraoperative.
G0275..................... Renal angio, cardiac cath........ N n/a N n/a n/a Intraoperative.
G0278..................... Iliac art angio,cardiac cath..... N n/a N n/a n/a Intraoperative.
G0288..................... Recon, CTA for surg plan......... S 0417 N n/a n/a Image Processing.
G0378..................... Hospital observation per hr...... Q 339 N n/a n/a Observation.
Q9951..................... LOCM >= 400 mg/ml iodine, 1ml.... K 9163 N n/a n/a Contrast Agent.
Q9953..................... Inj Fe-based MR contrast, 1ml.... K 1713 N n/a n/a Contrast Agent.
[[Page 66664]]
Q9954..................... Oral MR contrast, 100 ml......... K 9165 N n/a n/a Contrast Agent.
Q9955..................... Inj perflexane lip micros, ml.... K 9203 N n/a n/a Contrast Agent.
Q9956..................... Inj octafluoropropane mic, ml.... K 9202 N n/a n/a Contrast Agent.
Q9957..................... Inj perflutren lip micros, ml.... K 9112 N n/a n/a Contrast Agent.
Q9958..................... HOCM <= 149 mg/ml iodine, 1ml.... N n/a N n/a n/a Contrast Agent.
Q9959..................... HOCM 150-199mg/ml iodine, 1ml.... N n/a N n/a n/a Contrast Agent.
Q9960..................... HOCM 200-249mg/ml iodine, 1ml.... N n/a N n/a n/a Contrast Agent.
Q9961..................... HOCM 250-299mg/ml iodine, 1ml.... N n/a N n/a n/a Contrast Agent.
Q9962..................... HOCM 300-349mg/ml iodine, 1ml.... N n/a N n/a n/a Contrast Agent.
Q9963..................... HOCM 350-399mg/ml iodine, 1ml.... N n/a N n/a n/a Contrast Agent.
Q9964..................... HOCM >= 400mg/ml iodine, 1ml..... N n/a N n/a n/a Contrast Agent.
Q9965..................... LOCM 100-199mg/ml iodine, 1ml.... n/a n/a N n/a n/a Contrast Agent.
Q9966..................... LOCM 200-299mg/ml iodine, 1ml.... n/a n/a N n/a n/a Contrast Agent.
Q9967..................... LOCM 300-399mg/ml iodine, 1ml.... n/a n/a N n/a n/a Contrast Agent.
--------------------------------------------------------------------------------------------------------------------------------------------------------
e. Service-Specific Packaging Issues
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.'' Commenters to past rules have
suggested that certain 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
have historically considered 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. As discussed above regarding our packaging approach for
CY 2008, we have modified the historical considerations outlined above
in developing our policy for the CY 2008 OPPS. The Packaging
Subcommittee discussed many HCPCS codes during the March 2007 APC Panel
meeting, prior to development of the packaging approach discussed
above, and we have summarized and responded to the APC Panel's
packaging-related recommendations below. Three of the codes reviewed by
the Packaging Subcommittee at the March 2007 APC Panel meeting are
included in the seven categories of services identified for packaging
under the CY 2008 OPPS. For those three codes, we specifically applied
the proposed CY 2008 criteria for determining whether a code should be
proposed as packaged or separately payable for CY 2008. Specifically,
we determined whether the service is a dependent service falling into
one of the seven specified categories that is always or almost always
provided integral to an independent service. For those four codes that
were reviewed during the March 2007 APC Panel meeting but that do not
fit into any of the seven categories of codes that are part of our CY
2008 proposed packaging approach, we applied the packaging criteria
described above that were historically used under the OPPS. Moreover,
we took into consideration our interest in exploring the possibility of
expanding the size of payment groups for component services to provide
encounter-based and episode-of-care-based payment in the future in
order to encourage hospital efficiency and provide hospitals with
maximal flexibility to manage their resources.
In accordance with a recommendation of the APC Panel, for the CY
2007 OPPS, we implemented a new policy that designates certain codes as
``special'' packaged codes, assigned to status indicator ``Q'' under
the OPPS, where separate payment is provided if the code is reported
without any other services that are separately payable under the OPPS
on the same date of service. Otherwise, payment for the ``special''
packaged code is packaged into payment for the separately payable
services provided by the hospital on the same date. We note that these
``special'' packaged codes are a subset of those HCPCS codes that are
assigned to status indicator ``Q,'' which means that their payment is
conditionally packaged under the OPPS. We proposed to update our
criteria to determine packaged versus separate payment for ``special''
packaged HCPCS codes assigned to status indicator ``Q'' for CY 2008.
For CY 2008, payment for ``special'' packaged codes would be packaged
when these HCPCS codes are billed on the same date of service as a code
assigned to status indicator ``S,'' ``T,'' ``V,'' or ``X.'' When one of
the ``special'' packaged codes assigned to status indicator ``Q'' is
billed on a date of service without a code that is assigned to any of
the four status indicators noted above, the ``special'' packaged code
assigned to status indicator ``Q'' would be separately payable.
The Packaging Subcommittee identified areas for change for some
currently 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 2008, the Packaging Subcommittee
reviewed the packaging status of numerous HCPCS codes and reported its
findings to the APC Panel at its March 2007 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--
1. CMS place CPT code 76937 (Ultrasound guidance for vascular
access requiring ultrasound evaluation of potential access sites,
documentation of selected vessel patency, concurrent real-time
ultrasound visualization of vascular needle entry, with permanent
[[Page 66665]]
recording and reporting (list separately in addition to code for
primary procedure)) on the list of ``special'' packaged codes (status
indicator ``Q''). (Recommendation 1)
2. CMS evaluate providing separate payment for trauma activation
when it is reported on a claim for an ED visit, regardless of the level
of the emergency department visit. (Recommendation 2)
3. CMS place 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) on the
list of ``special'' packaged codes (status indicator ``Q'').
(Recommendation 3)
4. CMS place CPT code 0126T (Common carotid intima-media thickness
(IMT) study for evaluation of atherosclerotic burden or coronary heart
disease risk factor assessment) on the list of ``special'' packaged
codes (status indicator ``Q'') and that CMS consider mapping the code
to APC 340 (Minor Ancillary Procedures). (Recommendation 4)
5. CMS place CPT code 0069T (Acoustic heart sound recording and
computer analysis only) on the list of ``special'' packaged codes
(status indicator ``Q'') and that CMS exclude APC 0096 (Non-Invasive
Vascular Studies) as a potential placement for this CPT code.
(Recommendation 5)
6. CMS maintain the packaged status of HCPCS code A4306 (Disposable
drug delivery system, flow rate of less than 50 ml per hour) and that
CMS present additional data on this system to the APC Panel when
available. (Recommendation 6)
7. CMS reevaluate the packaged OPPS payment for CPT code 99186
(Hypothermia; total body) based on current research and availability of
new therapeutic modalities. (Recommendation 7)
8. The Packaging Subcommittee remains active until the next APC
Panel meeting. (Recommendation 8)
In addition, the Packaging Subcommittee reported its findings to
the APC Panel at its September 2007 meeting. The APC Panel accepted the
report of the Packaging Subcommittee, heard presentations on certain
packaged services, discussed the deliberations of the Packaging
Subcommittee, and recommended that--
9. CMS provide more data at the next APC Panel meeting on HCPCS
code A4306 (Disposable drug delivery system, flow rate of less than 50
mL per hour). (Recommendation 9)
10. The Packaging Subcommittee remains active until the next APC
Panel meeting. (Recommendation 10)
We address each of these recommendations in turn in the discussion
that follows.
Recommendation 1
For CY 2008, we proposed to maintain CPT code 76937 as a packaged
service. We are not adopting the APC Panel's recommendation to pay
separately for this code in some circumstances as a ``special''
packaged code. In the CY 2006 OPPS final rule with comment period (70
FR 68544 through 68545), in response to several public comments, we
reviewed in detail the claims data related to CPT code 76937. During
its March 2006 APC Panel meeting, after reviewing data pertinent to CPT
code 76937, the APC Panel recommended that CMS maintain the packaged
status of this code for CY 2007, and we accepted that recommendation.
During the March 2007 APC Panel meeting, after reviewing current data
and listening to a public presentation, the Panel recommended that we
treat this code as a ``special'' packaged code for CY 2008, noting that
certain uncommon clinical scenarios could occur where it would be
possible to bill this service alone on a claim, without any other
separately payable OPPS services.
We proposed to maintain CPT code 76937 as an unconditionally
packaged service for CY 2008, fully consistent with the proposed
packaging approach for the CY 2008 OPPS, as discussed above. Because
CPT code 76937 is a guidance procedure and we proposed to package
payment for all guidance procedures for CY 2008, we believe it is still
appropriate to maintain the unconditionally packaged status of this
code, which is a CPT designated add-on procedure that we expected to be
generally provided only in association with other independent services.
We applied the updated criteria for determining whether this service
should receive packaged or separately payment under the CY 2008 OPPS.
Specifically, we determined that this service was a supportive
ancillary service that was integral to an independent service,
resulting in our CY 2008 proposal to packaged payment for the service.
We discussed this code extensively in both the CY 2006 and CY 2007
final rules with comment period (70 FR 68544 through 68545; 71 FR 67996
through 67997). Our hospital claims data demonstrated that guidance
services were used frequently for the insertion of vascular access
devices, and we had no evidence that patients lacked appropriate access
to guidance services necessary for the safe insertion of vascular
access devices in the hospital outpatient setting. Because we believe
that ultrasound guidance would almost always be provided with one or
more separately payable independent procedures, its costs would be
appropriately bundled with the handful of vascular access device
insertion procedures with which it was most commonly performed. We
further believe that hospital staff chose 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.
Therefore, we do not believe that CPT code 76937 is an appropriate
candidate for designation as a ``special'' packaged code. The CY 2007
CPT book indicates that this code is an add-on code and should be
reported in addition to the code reported for the primary procedure.
According to our CY 2006 claims data available for the proposed rule,
this code was billed over 60,000 times, yet less than one-tenth of 1
percent of all claims for the procedure were billed without any
separately payable OPPS service on the claim. Because this code is
provided alone only extremely rarely, we believe this code would not be
appropriately treated as a ``special'' packaged code. Therefore, we
proposed to continue to unconditionally package CPT code 76937 for CY
2008.
We received several comments that referenced CPT code 76937 in
discussions related to the packaged status of guidance services in
general. Those comments are summarized and responded to in section
II.4.c.1 of this final rule with comment period. As noted in that
section, we are finalizing our proposal, without modification, to
unconditionally package CPT code 76937 for CY 2008.
Recommendation 2
For CY 2008, we proposed to maintain the packaged status of revenue
code 068x, trauma response, when the trauma response is provided
without critical care services. During the August 2006 APC Panel
meeting, the APC Panel encouraged CMS to pay differentially for
critical care services provided with and without trauma activation. For
CY 2007, as a result of the APC Panel's August 2006 discussion and our
own data analysis, we finalized a policy to pay differentially for
critical care provided with and without trauma activation. The CY 2007
payment rate
[[Page 66666]]
for critical care unassociated with trauma activation is $405.04 (APC
0617, Critical Care), while the payment rate for critical care
associated with trauma activation is $899.58 (APC 0617 and APC 0618
(Trauma Response with Critical Care)). During the March 2007 APC Panel
meeting, a presenter requested that CMS also pay differentially for
emergency department visits provided with and without trauma
activation. Two organizations that submitted comment letters for the
APC Panel's review specifically requested separate payment for revenue
code 068x every time it appears on a claim, regardless of the other
services that were billed on that claim. The APC Panel recommended that
CMS evaluate providing separate payment for trauma activation when it
is reported on a claim for an emergency department visit, regardless of
the level of the emergency department visit.
After accepting the APC Panel's recommendation and evaluating this
issue, we continue to believe that, while it is currently appropriate
to pay separately for trauma activation when billed in association with
critical care services, it is also currently appropriate to maintain
the packaged payment status of revenue code 068x when trauma response
services are provided in association with both clinic and emergency
department visits under the CY 2008 OPPS. As mentioned above, we are
exploring the possibility of expanding the size of the payment groups
under the OPPS to move toward encounter-based and episode-of-care-based
payments in order to encourage maximum hospital efficiency with a focus
on budget-neutral value-based purchasing. Because trauma activation in
association with emergency department or clinic visits would always be
provided in the same hospital outpatient encounter as the visit for
care of the injured Medicare beneficiary, packaging payment for trauma
activation when billed in association with both clinic and emergency
department visits is most consistent with our proposed packaging
approach. We are also concerned that unpackaging payment for trauma
activation in those circumstances where the trauma response would be
less likely to be essential to appropriately treating a Medicare
beneficiary would reduce the incentive for hospitals to provide the
most efficient and cost-effective care. We note that, while we proposed
for CY 2008 to continue to provide separate payment for trauma
activation in association with critical care services, we may
reconsider this payment policy for future OPPS updates as we explore
the possibility of developing encounter based and episode-of-care-based
payment approaches.
Furthermore, continued packaged payment for trauma activation when
unassociated with critical care is consistent with the principles of
the OPPS, where hospitals receive payment based on the median cost
related to all of the hospital resources associated with the main
service provided. In various situations, each hospital's costs may be
higher or lower than the median cost used to set payment rates. In
light of our packaging approach for the CY 2008 OPPS, we believe it is
particularly important not to make any changes in our payment policies
for other services that are not fully aligned with promoting efficient,
judicious, and deliberate care decisions by hospitals that allow them
maximum flexibility to manage their resources through encouraging the
most cost-effective use of hospital resources in providing the care
necessary for the treatment of Medicare beneficiaries. Packaging
payment encourages hospitals to establish protocols that ensure that
services are furnished only when they are medically necessary and to
carefully scrutinize the services ordered by practitioners to minimize
unnecessary use of hospital resources.
Therefore, we are adopting the APC Panel's recommendation that we
evaluate providing separate payment for revenue code 068x when provided
in association with emergency department visits. For CY 2008, after our
thorough assessment, we proposed to maintain the packaged status of
revenue code 068x, except when revenue code 068x is billed in
association with critical care services.
We did not receive any comments on this proposal. Therefore, we are
finalizing our proposal, without modification, to maintain the packaged
status of revenue code 068x, trauma response, when the trauma response
is provided without critical care services.
We note that we do not anticipate that the new composite Extended
Assessment and Management APCs, 8002 and 8003, will affect this policy
in any way.
Recommendation 3
For CY 2008, we proposed to maintain the unconditionally packaged
status of 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) and 0175T. These
services involve 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. CPT code 0152T (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; chest radiograph(s)
(List separately in addition to code for primary procedure)), the
predecessor code to CPT codes 0174T and 0175T, was indicated as an add-
on code to chest x-ray CPT codes for CY 2006, according to the AMA's CY
2006 CPT book. However, on July 1, 2006, the AMA released to the public
an update that deleted CPT codes 0152T and replaced it with the two new
Category III CPT codes 0174T and 0175T.
In its March 2006 presentation to the APC Panel, before the AMA had
released the CY 2007 changes to CPT code 0152T, a presenter 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 same presenter requested that we
assign both of the 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 was unclear as to whether remote referred to time,
geography, or a specific provider. They believed 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 service (chest x-ray) that would be separately paid.
Thus, even in these cases, payment for the CAD service
[[Page 66667]]
could be appropriately packaged. After significant and lengthy
deliberation, the APC Panel recommended that we package payment for
both of the new CPT codes, 0174T and 0175T, for CY 2007.
In its March 2007 presentation to the APC Panel, the same presenter
requested that we pay separately for CPT codes 0174T and 0175T, mapping
them to New Technology APC 1492, with a payment rate of $15. The
presenter indicated that chest x-ray CAD is not a screening tool and
should only be billed to Medicare when applied to chest x-rays
suspicious for lung cancer. The presenter also explained that
additional and distinct hospital resources are required for chest x-ray
CAD that are not required for a standard chest x-ray. In addition,
remote chest x-ray CAD described by CPT code 0175T can be performed at
a different time or location or by a different provider than the chest
x-ray service. The presenter expressed concern that if hospitals were
not paid separately for this technology, hospitals would not be able to
provide it, thereby limiting beneficiary access to chest x-ray CAD. The
APC Panel recommended conditional packaging as a ``special'' packaged
code for CPT code 0175T, but did not recommend a change to the
unconditionally packaged status of CPT code 0174T. We are not adopting
the APC Panel's recommendation for designation of CPT code 0175T as a
``special'' packaged code under the CY 2008 OPPS.
We believed and continue to believe that packaged payment for
diagnostic chest x-ray CAD under a prospective payment methodology for
outpatient hospital services is most appropriate. We proposed to
maintain CPT codes 0174T and 0175T as unconditionally packaged services
for CY 2008, fully consistent with the packaging approach for the CY
2008 OPPS, as discussed above. Because CPT codes 0174T and 0175T are
supportive ancillary services that fit into the ``image processing''
category, and we proposed to package payment for all image processing
services for CY 2008, we believe it is appropriate to maintain the
packaged status of these code. We applied the updated criteria for
determining whether these two CAD services should receive packaged or
separate payment. Specifically, we determined that this service is a
dependent service that is integral to an independent service, in this
case, the chest x-ray or other OPPS service that we would expect to be
provided in addition to the CAD service.
After hearing many public presentations and discussions regarding
the use of chest x-ray CAD, we continue to believe that even the remote
service would almost always be provided by a hospital either in
conjunction with other separately payable services or under
arrangement. For example, if a physician orders a chest x-ray and CAD
service to be performed at hospital A and hospital A, which does not
have the CAD technology, sends the chest x-ray to hospital B for the
performance of chest x-ray CAD, hospital B could only provide the CAD
service if it were provided under arrangement, to avoid the OPPS
unbundling prohibition. Assuming that the CAD service was provided
under arrangement, hospital A would bill for the chest x-ray CAD that
was performed by hospital B and would pay hospital B for the service
provided. In that case, hospital A would also bill the chest x-ray
service that it provided. In another scenario that has been described
to us, if a physician were to send a patient to a hospital clinic with
the patient's chest x-ray for consultation, we believe that the patient
would likely receive a visit service, in addition to the chest x-ray
CAD. Therefore, in both of these circumstances, payment for the chest
x-ray CAD would be appropriately packaged into payment for the
separately payable services with which it was provided.
We also do not believe that CPT code 0175T should be treated as a
``special'' packaged code. As discussed earlier in this section with
regard to our packaging approach for image processing services for CY
2008, we are concerned with establishing payment policies that could
encourage certain inefficient and more costly service patterns,
particularly for those services that do not need to be provided as a
face-to-face encounter with the patient. If we were to assign CPT code
0175T to ``special'' packaged status, we would likely create an
incentive for hospitals to perform chest x-ray CAD remotely, for
example, several days after performance of the initial chest x-ray,
rather than immediately following the chest x-ray on the same day, to
enable the hospital to receive separate payment for the service. In CY
2005, there were approximately 7.3 million claims for all chest x-ray
services in the HOPD, so a payment policy that could induce such
changes in service delivery would be problematic in light of our
commitment to encouraging the most efficient and cost-effective care
for Medicare beneficiaries. Creating such perverse payment incentives
through conditional packaging is a particular problem for those
services that do not need a face-to-face encounter with the patient. In
fact, as part of our proposed CY 2008 packaging approach, we also
proposed to unconditionally package payment in CY 2008 for several
other image processing services that are not always performed face-to-
face, including HCPCS code G0288 (Reconstruction, computer tomographic
angiography of aorta for surgical planning for vascular surgery) and
CPT code 76377 (3D rendering with interpretation and reporting of
computed tomography, magnetic resource imaging, ultrasound, or other
tomographic modality; requiring image postprocessing on an independent
workstation). As noted in section II.A.4.c.(2) of this final rule with
comment period, we are finalizing our proposal for those codes and they
will be unconditionally packaged for CY 2008.
The proposed unconditionally packaged treatment of the two CPT
codes for chest x-ray CAD is fully consistent with the packaging
approach for the CY 2008 OPPS, as discussed above, and the principles
and incentives for efficiency inherent in a prospective payment system
based on groups of services. Packaging these services creates
incentives for providers to furnish services in the most cost-effective
way and provides them with the most flexibility to manage their
resources. As stated above, packaging encourages hospitals to establish
protocols that ensure that services are furnished only when they are
medically necessary and to carefully scrutinize the services ordered by
practitioners to minimize unnecessary use of hospital resources.
Therefore, we proposed to continue to unconditionally package payment
for CPT codes 0174T and 0175T for CY 2008.
Comment: One commenter requested that CPT codes 0174T and 0175T,
which were provided interim assignments in CY 2007 be assigned to
status indicator ``S'' and be paid separately with a payment rate of
$15. That commenter then requested conditional payment for both of
these CPT codes, status indicator ``Q'' assignment, and a payment rate
of $15. The commenter indicated that this technology is an important
diagnostic test for lung cancer patients, and that insufficient payment
will limit access to this cost-effective diagnostic tool.
Response: As discussed extensively above, after thorough discussion
with the APC Panel and repeated review by our clinical advisors, we
continue to believe that these codes are appropriately unconditionally
packaged.
For CY 2008, we are finalizing our proposal without modification to
unconditionally package CPT codes
[[Page 66668]]
0174T and 0175T for CY 2008. We note that these codes fall into the
category of the image processing codes that are packaged for the CY
2008 OPPS.
Recommendation 4
For CY 2008, we adopted the APC Panel's recommendation and proposed
to add CPT code 0126T to the list of ``special'' packaged codes and
assign this code to APC 0340 (Minor Ancillary Procedures).
This service describes an ultrasound procedure that measures common
carotid intima-media thickness to evaluate a patient's degree of
atherosclerosis. This code became effective January 1, 2006. We
received a comment to the CY 2007 proposed rule requesting that this
code become separately payable for CY 2007. At that point, we had no
cost data for the service and, as discussed in the CY 2007 OPPS/ASC
final rule with comment period (71 FR 67998), we reviewed this code
with the Packaging Subcommittee, as is our standard procedure for codes
that we are asked to review during the comment period. The APC Panel
noted that this service could sometimes be provided to a patient
without any other separately payable services. Therefore, the APC Panel
recommended that we add this code to the list of ``special'' packaged
codes and pay for it separately when it is provided without any other
separately payable services on the same day. For circumstances when
this code is paid separately, the APC Panel recommended that we
consider assigning this code to APC 0340.
While we continue to believe that this procedure would not commonly
be provided alone, we adopted the APC Panel recommendation and proposed
to treat this code as a ``special'' packaged code subject to
conditional packaging, mapping to APC 0340 for CY 2008 when it would be
separately paid. This is fully consistent with the packaging approach
for the CY 2008 OPPS, as discussed above. Because CPT code 0126T is
almost always performed during another procedure, and we proposed to
package payment for all intraoperative procedures for CY 2008, we
believe it is appropriate to designate this CPT code as a ``special''
packaged code. We applied the updated criteria for determining whether
this service should receive packaged or separate payment. Specifically,
we determined that this service is usually a dependent service that is
integral to an independent service, but that it could sometimes be
provided without an independent service.
As with all ``special'' packaged codes, we will closely monitor
cost data and frequency of separate payment for this procedure as soon
as we have more claims data available.
We did not receive any comments related to this proposal.
Therefore, we are finalizing our proposal without modification to
designate CPT code 0126T as a ``special'' packaged code for CY 2008.
This code is an ``STVX-packaged'' code.
Recommendation 5
For CY 2008, we proposed to maintain the packaged status of CPT
code 0069T, and we are not adopting the APC Panel's recommendation to
designate this service as a ``special'' packaged code. This 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. CPT code 0069T was an add-on code to an
electrocardiography (EKG) service for CYs 2005 and 2006. However,
effective January 1, 2007, the AMA changed the code descriptor to
remove the add-on code designation for CPT code 0069T. This code has
been packaged under the OPPS since CY 2005.
During the August 2005 APC Panel meeting, the APC Panel recommended
packaging CPT code 0069T for CY 2005. In its March 2006 presentation to
the APC Panel, a presenter 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 presenter stated 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. Ultimately, the APC Panel recommended assigning this
service to a separately payable status indicator. However, during the
August 2006 meeting, the APC Panel further discussed CMS' proposal to
package payment for CPT code 0069T for CY 2007 and considered the CY
2007 code descriptor change, finally recommending that CMS continue to
package this code for CY 2007.
During the March 2007 APC Panel meeting, the same presenter
requested that we pay separately for this service and assign it to APC
0096 (Non-Invasive Vascular Studies) or to APC 0097 (Cardiac and
Ambulatory Blood Pressure Monitoring), with CY 2007 payment rates of
$94.06 and $62.85, respectively. The presenter stated that the
estimated true cost of this service lies between $62 and $94. The
presenter clarified that this service is usually provided with an EKG,
but noted that the test is sometimes provided without an EKG, according
to its revised code descriptor for CY 2007. The presenter agreed that
it would be rare for the acoustic heart sound procedure to be performed
alone without any other separately payable OPPS services. The APC Panel
recommended that we place CPT code on the list of ``special'' packaged
codes and that we exclude APC 0096 as a potential placement for this
CPT code.
Because this service does not fit into one of the seven identified
categories of packaged codes proposed for the CY 2008 OPPS, we followed
our historical packaging guidelines to determine whether to maintain
the packaged status of this code or to pay for it separately. Based on
the clinical uses that were described during the March 2007 and earlier
APC Panel meetings, APC Panel discussions, and our claims data review,
we continue to believe that it is highly unlikely that CPT code 0069T
would be performed in the HOPD as a sole service without other
separately payable OPPS services. In addition, our data indicate that
this service is estimated to require only minimal hospital resources.
Based on CY 2006 claims, we had only 8 single claims for CPT code
0069T, with a median line-item cost of approximately $5, consistent
with its low expected cost. Therefore, we believe that payment for CPT
code 0069T is appropriately packaged because it would usually be
closely linked to the performance of an EKG or other separately payable
cardiac service, would rarely, if ever, be the only OPPS service
provided to a patient in an encounter, and has a low estimated resource
cost. The proposed packaged treatment of this code is consistent with
the principles and incentives for efficiency inherent in a prospective
payment system based on groups of services. Therefore, we proposed to
continue to package payment for CPT code 0069T for CY 2008.
We did not receive any comments related to this proposal.
Therefore, we are finalizing our proposal, without modification, to
continue to package payment for CPT code 0069T for CY 2008.
Recommendation 6
For CY 2008, we proposed to adopt the APC Panel's recommendation
and maintain the packaged status of HCPCS code A4306. We note that at
its
[[Page 66669]]
September 2007 APC Panel meeting, the Panel recommended specifically
that CMS provide more data at the next meeting on this code.
HCPCS code A4306 describes a disposable drug delivery system with a
flow rate of less than 50 ml per hour. As discussed during the March
2007 APC Panel meeting, there is a particular disposable drug delivery
system that is specifically used to treat postoperative pain. Since the
implementation of the OPPS, this code was assigned to status indicator
``A,'' indicating that it was payable according to another fee
schedule, in this case, the Durable Medical Equipment (DME) fee
schedule. There were discussions during CYs 2005 and 2006 between CMS
and a manufacturer, and it was determined that this code should be
removed from the DME fee schedule as this code does not describe DME.
For CY 2007, HCPCS code A4306 is payable under the OPPS, with status
indicator ``N'' indicating that its payment is unconditionally
packaged.
One presenter to the APC Panel requested that we pay separately for
this supply under the OPPS. For CY 2007, we packaged payment for this
code because it is considered to be a supply, and since the inception
of the OPPS the established payment policy packages payment for
supplies because they are directly related and integral to an
independent service furnished under the OPPS.
Our CY 2006 claims data indicate that HCPCS code A4306 was billed
on OPPS claims 1,773 times, yielding a line-item median cost of
approximately $3. The APC Panel and a presenter believe that this code
may not always be appropriately billed by hospitals as the data also
show that this code was billed together with computed tomography (CT)
scans of the thorax, abdomen, and pelvis approximately 40 percent of
the time that this supply was reported. The APC Panel speculated that
this code may be currently reported when other types of drug delivery
devices are utilized for nonsurgical procedures or for purposes other
than the treatment of postoperative pain. Therefore, the APC Panel
requested that we share additional data when available.
In summary, because HCPCS code A4306 represents a supply and
payment of supplies is packaged under the OPPS according to
longstanding policy, we proposed to maintain the packaged status of
HCPCS code A4306 for CY 2008.
Comment: A commenter supported CMS' proposal to maintain the
packaged status of HCPCS code A4306 for CY 2008. The commenter
suspected that this code is misreported by hospitals and estimated that
the true cost of the supply is between $20 and $60. The commenter
requested that CMS provide instructions to hospitals on the appropriate
revenue center for this supply and contact the AHA coding clinic
regarding the need for better HCPCS code instructions for this supply.
Response: In general, we give hospitals the flexibility to report
charges under whichever revenue code the hospital believes is most
appropriate. In addition, it is not our usual practice to refer codes
to the AHA coding clinic for review. Instead, we encourage the
commenter to submit any questions or requests for clarification to the
AHA coding clinic, if appropriate.
We are finalizing without modification our proposal to continue to
package payment for HCPCS code A4306 for CY 2008. In addition, with
respect to APC Panel Recommendation 9, we will provide the APC Panel
with more cost data related to this code at its next meeting.
Recommendation 7
For CY 2008, we proposed to maintain the packaged status of CPT
code 99186, consistent with the APC Panel's recommendation that we
reevaluate the packaged OPPS payment for CPT code 99186 based on
current research and the availability of new therapeutic modalities.
This service describes induced total body hypothermia that is performed
on some post-cardiac arrest patients to avoid or lessen brain damage.
The service has been packaged since the implementation of the OPPS. One
presenter to the APC Panel at the March 2007 meeting requested that
this code be assigned a separately payable status indicator under the
OPPS. The presenter expressed concern that hospitals that provide this
service and subsequently transfer the patient to another hospital prior
to admission are not adequately paid for their services.
Because this service does not fit into one of the seven identified
categories of packaged codes proposed for the CY 2008 OPPS, we followed
our historical packaging guidelines to determine whether to maintain
the packaged status of this code or to pay for it separately. Claims
data indicate that this code was billed 39 times under the OPPS in CY
2006 and was never billed without another separately payable service on
the same date. The proposed CY 2008 median cost for this code was
approximately $35, with individual costs ranging from approximately $17
to $69, likely reflecting the costs associated with traditional methods
of inducing total body hypothermia, such as ice packs applied to the
body. In fact, the presenter noted that a technologically advanced
total body hypothermia system costs $30,000, with an additional cost of
$1,600 per disposable body suit. As expected, our claims data showed
that this service was provided most frequently with high level
emergency department visits and critical care services.
As we noted in the CY 2008 proposed rule, we believed that the
circumstances in which total body hypothermia would be provided to a
Medicare beneficiary and billed under the OPPS were extremely rare, as
patients requiring this therapy would almost always be admitted as
inpatients if they survive. Moreover, in the uncommon situation where a
patient presents to one hospital and then is cooled and transported to
another hospital without admission to the first hospital, payment for
the hypothermia service would be most appropriately packaged into
payment for the many other separately payable services that it most
likely accompanied and that would be paid to the first hospital under
the OPPS.
In addition, consistent with the principles and incentives for
efficiency inherent in a prospective payment system based on groups of
services, packaging payment for this procedure that is highly
integrated with other services provided in the hospital outpatient
encounter creates incentives for providers to furnish services in the
most cost-effective way. In situations where there are a variety of
supplies that could be used to furnish a service, some of which are
more expensive than others, packaging encourages hospitals to use the
most cost-effective item that meets the patient's needs.
This code was discussed by the APC Panel members during the
September 2007 APC Panel meeting, but they made no official
recommendation.
We did not receive any comments related to our proposal. Therefore,
we are finalizing our proposal to maintain the packaged status of CPT
code 99186 for CY 2008.
Recommendation 8
We note that the Packaging Subcommittee remains active. See
Recommendation 10 below.
Recommendation 9
As noted in Recommendation 6, in accordance with the APC Panel's
recommendation, we will provide more cost data related to HCPCS code
A4306 (Disposable drug delivery system, flow
[[Page 66670]]
rate of less than 50 mL per hour) for the APC Panel's review at its
next meeting.
Recommendation 10
In response to the APC Panel's recommendation for the Packaging
Subcommittee to remain active until the next APC Panel meeting, 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, and we also encourage recommendations of
specific services or procedures whose payment would be most
appropriately packaged under the OPPS. 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
Sec. 419.21 that implement this provision specify that payments under
the OPPS will be made for partial hospitalization services furnished by
CMHCs as well as those furnished to hospital outpatients. Section
1833(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, which
includes a discussion of the decision to base relative payment rates on
median cost, we refer readers to the April 7, 2000 OPPS final rule with
comment period (65 FR 18482).
Historically, the median per diem cost for CMHCs greatly exceeded
the median per diem cost for hospital-based PHPs and fluctuated
significantly from year to year, while the median per diem cost for
hospital-based PHPs 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 this final rule with comment period and in the CY
2004 OPPS final rule with comment period (68 FR 63470), we also believe
that some CMHCs manipulated their charges in order to inappropriately
receive outlier payments.
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 the CY 2005 OPPS update, the CMHC median per diem cost was $310,
the hospital-based PHP median per diem cost was $215, and the combined
CMHC and hospital-based median per diem cost was $289. We believed that
the reduction in the CY 2005 CMHC median per diem cost compared to
prior years 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 dropped to $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 updated 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.
Due to concern that this amount may not cover the cost for PHPs, as
stated in the CY 2006 OPPS final rule with comment period (70 FR 68548
and 68549), we applied a 15-percent reduction to the combined hospital-
based and CMHC median per diem cost to establish the CY 2006 PHP APC.
(We refer readers to the CY 2006 OPPS final rule with comment period
for a full discussion of how we established the CY 2006 PHP rate (70 FR
68548).) We stated our belief 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 stated that 15 percent was an
appropriate reduction because it recognized decreases in median per
diem costs in both the hospital data and the CMHC data, and also
reduced 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 could be calculated based
on better empirical data (70 FR 68548). To apply this methodology for
CY 2006, we reduced the CY 2005 combined unscaled hospital-based and
CMHC median per diem cost of $289 by 15 percent, resulting in a
combined median per diem cost of $245.65 for CY 2006.
For the 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, and
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
[[Page 66671]]
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 was noted as the average charge for CY
2003 ($1,184).
The combined hospital-based and CMHC median per diem cost would
have been $175 for CY 2007. Rather than allowing the PHP median per
diem cost to drop to this level, we proposed to reduce the PHP median
cost by 15 percent, similar to the methodology used for the CY 2006
update. However, after considering all public comments received
concerning the proposed CY 2007 PHP per diem rate and results obtained
using the more current data, we modified our proposal. We made a 5-
percent reduction to the CY 2006 median per diem rate to provide a
transitional path to the per diem cost indicated by the data. This
approach accounted for the downward direction of the data and addressed
concerns raised by commenters about the magnitude of another 15-percent
reduction in 1 year. Thus, 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.
2. PHP APC Update for CY 2008
As noted in the CY 2008 OPPS/ASC proposed rule (72 FR 42691), for
the past 2 years, we were concerned that we did not have sufficient
evidence to support using the median per diem cost produced by the most
current year's PHP data. After extensive analysis, we now believe the
data reflects the level of cost for the type of services that are being
provided. This analysis included an examination of revenue-to-cost
center mapping, refinements to the per diem methodology, and an in-
depth analysis of the number of units of service per day.
As stated in the CY 2008 proposed rule (72 FR 42691), the CY 2006
and CY 2007 OPPS updates data have produced median costs that we
believed were too low to cover the cost of a program that typically
spans 5 to 6 hours per day. However, we continued to observe a clear
downward trend in the data. We stated that if the data continued to
reflect a low PHP per diem cost in CY 2008, we expected to continue the
transition of decreasing the PHP median per diem cost to an amount that
is more reflective of the data.
We received a comment on the CY 2007 proposed rates that CMS
understated the PHP median cost by not using a hospital-specific CCR
for partial hospitalization. In our response to this comment in the CY
2007 OPPS/ASC final rule with comment period (71 FR 68000), we noted
that, although most hospitals do not have a cost center for partial
hospitalization, we used the CCR as specific to PHP as possible. The
following CMS Web site contains the revenue-code-to-cost-center
crosswalk: http://www.cms.hhs.gov/HospitalOutpatientPPS/03--
crosswalk.asp#TopOfPage.
As noted in the proposed rule (72 FR 42691), this crosswalk
indicates how 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 most revenue codes that are used in the OPPS median
calculations, starting with the most specific, and ending with the most
general. Typically, we map the revenue code to the most specific cost
center with a provider-specific CCR. However, if the hospital does not
have a CCR for any of the listed cost centers, we consider the overall
hospital CCR as the default. For partial hospitalization, the revenue
center codes billed by PHPs are mapped to Primary Cost Center 3550
``Psychiatric/Psychological Services''. If that cost center is not
available, they are mapped to the Secondary Cost Center 6000
``Clinic.'' We use the overall facility CCR for CMHCs because PHPs are
CMHCs' only Medicare cost, and CMHCs do not have the same cost
structure as hospitals. Therefore, for CMHCs, we use the CCR from the
outpatient provider-specific file.
As indicated in the proposed rule (72 FR 42691), closer examination
of the revenue-code-to-cost-center crosswalk revealed that 10 of the
revenue center codes (shown in the table below) that are common among
hospital-based PHP claims did not map to a Primary Cost Center 3550
``Psychiatric/Psychological Services'' or a Secondary Cost Center of
6000 ``Clinic.''
------------------------------------------------------------------------
Revenue center code Revenue center description
------------------------------------------------------------------------
0430............................. Occupational Therapy.
0431............................. Occupational Therapy: Visit charge.
0432............................. Occupational Therapy: Hourly charge.
0433............................. Occupational Therapy: Group rate.
0434............................. Occupational Therapy: Evaluation/re-
evaluation.
0439............................. Occupational Therapy: Other
occupational therapy.
0904............................. Psychiatric/Psychological Treatment:
Activity therapy.
0940............................. Other Therapeutic Services.
0941............................. Other Therapeutic Services:
Recreation Rx.
0942............................. Other Therapeutic Services: Education/
training.
------------------------------------------------------------------------
We believed these 10 revenue center codes did not map to either a
Primary Cost Center 3550 ``Psychiatric/Psychological Services'' or a
Secondary Cost Center 6000 ``Clinic'' because these codes may be used
for services that are not PHP or psychiatric related. For example, the
majority of Occupational Therapy services are not furnished to PHP
patients and, therefore, these services should be appropriately mapped
to a Primary Cost Center 5100 ``Occupation Therapy'' (the general
Occupational Therapy Cost Center). Another example would be claims for
Diabetes Education, which is also not furnished to PHP patients.
For this final rule with comment period, we have updated this
analysis using updated claims and CCR data for PHP claims. Again, we
remapped the 10 revenue center codes described earlier in this section
to a Primary Cost Center 3550 ``Psychiatric/Psychological Services'' or
a Secondary Cost Center 6000 ``Clinic''. Once we remapped the codes, we
computed an alternate cost for each line item of the CY 2006 hospital-
based PHP claims. There are a total of 723,749 line items in the CY
2006 hospital-based PHP claims. Prior to remapping, there were 320,504
line items where a default CCR was used to estimate costs. After the
remapping, there were 160,351 line items left defaulting to the
hospitals' overall CCR. While this remapping creates a more accurate
estimate of PHP per diem costs for a significant number of claims,
again there was not a large change in the resulting median per diem
cost. The median per diem costs for hospital-based PHPs increased by $5
(from $172 to $177). We note that, unlike the proposed rule, this final
rule analysis was done using the revised methodology for computing per
diem costs described below. We received no public comments in
opposition to the proposed change in remapping revenue codes to
alternate cost centers. Therefore, we are adopting this proposed change
beginning in CY 2008.
As part of our effort to produce the most accurate per diem cost
estimate, we have reexamined our methodology for computing the PHP per
diem cost. Section 1833(t)(2)(C) of the Act requires that we establish
relative payment weights based on median (or mean, at
[[Page 66672]]
the election of the Secretary) hospital costs determined by 1996 claims
data and data from the most recent available cost reports. As explained
in section II.B.1. of this final rule with comment period, payment to
providers under OPPS for PHP services 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. Other than being a per diem payment, we use the
general OPPS ratesetting methodology for determining median cost.
As we have described in prior Federal Register notices, our current
method for computing per diem costs is as follows: We use data from all
hospital bills reporting condition code 41, which identifies the claim
as partial hospitalization, and all bills from CMHCs. We use 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 are then
computed by summing the line-item costs on each bill and dividing by
the number of days of PHP care provided on the bill. These computed per
diem costs are arrayed from lowest to highest and the middle value of
the array is the median per diem cost.
As indicated in the proposed rule (72 FR 42692), we have developed
an alternate way to determine median cost by computing a separate per
diem cost for each day rather than for each bill. Under this method, a
cost is computed separately for each day of PHP care. When there are
multiple days of care entered on a claim, a unique cost is computed for
each day of care. All of these costs are then arrayed from lowest to
highest and the middle value of the array would be the median per diem
cost.
We proposed to adopt this alternative method of computing PHP per
diem median cost because we believe it produces a more accurate
estimate because each day gets an equal weight towards computing the
median. In light of the stabilizing trend in the data, and the
robustness of recent data analysis, we believe it is now appropriate to
adopt this method. We believe this method for computing a PHP per diem
median cost more accurately reflects the costs of a PHP and uses all
available PHP data. We received no public comments in opposition to the
revised method for computing per diem cost, although we did receive a
few public comments critical of our current method of computing per
diem costs. (These public comments and our response are addressed
below.) Therefore, we are adopting this proposed change beginning in CY
2008.
As noted previously, for the past 2 years, the data have produced
median costs that we believed were too low to cover the cost of a
program that typically spans 5 to 6 hours per day. This length of day
would include five or six services with a break for lunch. We looked at
the number of units of service being provided in a day of care, as a
possible explanation for the low per diem cost for PHP. Our analysis
revealed that both hospital based and CMHC PHPs have a significant
number of days where fewer than 4 units of service were provided.
Using updated data from the CY 2008 proposed rule, specifically, 64
percent of the days that CMHCs were paid were for days where 3 or less
units of services were provided, and 31 percent of the days that
hospital-based PHPs were paid were for days where 3 or less units of
service were provided. We continue to believe these findings are
significant because they may explain a lower per diem cost. Based on
these updated findings, we computed median per diem costs in two
categories:
(a) All days.
(b) Days with 4 units of service or more (removing days with 3
services or less).
These updated median per diem costs were computed separately for
CMHCs and hospital based PHPs and are shown in the table below:
------------------------------------------------------------------------
Hospital-
CMHCs based PHPs Combined
------------------------------------------------------------------------
All Days......................... $172 $177 $172
Days with 4 units or more........ 192 189 192
------------------------------------------------------------------------
As expected, excluding the low unit days resulted in a higher
median per diem cost estimate. However, if the programs have many ``low
unit days,'' their cost and Medicare payment should reflect this level
of service. It would not be appropriate to set the PHP rate to exclude
the ``low unit days'' because these days are covered PHP days. We
believe the analysis of the number of units of service per day supports
a lower per diem cost. Therefore, including all days supports the data
trend towards a lower per diem cost and we believe more accurately
reflects the costs of providing PHP services.
Although the minimum number of PHP services required in a PHP day
is three, it was never our intention that this represented the number
of services to be provided in a typical PHP day. Our intention was to
cover days that consisted of only three services, generally because a
patient was transitioning towards discharge (or a patient who is
transitioning at the beginning of their PHP stay). Rather than set
separate rates for half-days and full-days, we believed it was
appropriate to set one rate that would be paid for all PHP days,
including those for patients transitioning towards discharge (or
admission). We intended that the PHP benefit is for a full day, with
shorter days only occurring while a patient transitions into or out of
the PHP.
However, as indicated in the data, many programs have these ``low
unit days,'' and we believe their cost and Medicare payment should
reflect this level of service. It would not be appropriate to set the
PHP rate excluding the low unit days because these days are covered.
Again, we believe the data support the estimated per diem cost under
$200 that we have observed.
We believed the most appropriate payment rate for PHPs is computed
using both hospital-based and CMHC PHP data, including the remapped
data for all days, resulting in a median per diem cost of $178.
Therefore, we proposed a CY 2008 APC PHP per diem cost of $178.
We received a large number of public comments on our proposal. A
summary of the public comments received and our responses follow.
Comment: A number of commenters expressed concern about the
magnitude of the PHP per diem rate reduction, particularly in light of
the reductions over the past few years. Many commenters believe that
such a reduction would reduce the financial viability and possibly lead
to the closure of many PHPs, thus affecting access to this crucial
service that serves vulnerable populations. Many commenters stated that
PHPs are an
[[Page 66673]]
integral part of the continuum of care, and if programs were forced to
close, there would be an increase in the length and number of more
costly inpatient hospital stays. In addition, because hospital
outpatient mental health services paid under the OPPS are capped at the
PHP per diem rate, many commenters were concerned about overall access
to outpatient mental health treatment. The majority of commenters
requested that CMS freeze the PHP per diem rate at the CY 2007 level,
and some suggested inflating this rate each year by the consumer price
index or market basket update. In addition, several patients were
concerned that the proposed 24-percent reduction in payment would
negatively impact their ability to continue therapy. One commenter
requested that CMS limit the annual reduction to 5 percent, phasing in
the reduction over several years if necessary.
Response: For this CY 2008 final rule with comment period, we
analyzed 12 months of more current data for hospital and CMHC PHP
claims for PHP services furnished between January 1, 2006 and December
31, 2006. These claims data are more current than the CY 2008 proposed
rule claims data because the data include claims paid through June 30,
2007. We also used the most currently available CCRs to estimate costs.
Using these updated data, we recreated the analysis performed for the
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 decreased $6 to $172, while the median per diem cost for
hospital based PHPs decreased $9 to $177. The combined median per diem
cost, which is computed from both hospital-based and CMHC PHP data,
decreased $6 to $172. The CY 2006 average charge per day for CMHCs was
$615, similar to the figure noted in the CY 2007 proposed rule ($613)
and slightly lower than the average charge per day for hospital-based
PHPs ($631).
The data in this area have been volatile in the past and CMS must
establish a payment amount that reflects the intensity of the PHP, and
that also considers that costs for providing PHP services are
declining. We proposed two refinements to the methodology for computing
the PHP median, however, these refinements did not appreciably impact
the median per diem cost. We received no public comments in opposition
to these refinements and, therefore, we are adopting them in this final
rule with comment period. Thus, for CY 2008, we remapped the revenue
codes to the most appropriate cost centers and computed the median
using a per day methodology (as described earlier in this section).
In addition, based on our data analysis, we have determined that
CMHCs (and hospital-based PHPs to a lesser extent) are furnishing a
substantial number of low unit days. Although these are all covered
days in the context of existing Medicare guidelines, PHPs are furnished
in lieu of psychiatric hospitalization and are intended to be more
intensive than a half-day program. While the guidelines have allowed a
minimum of three services per day, this was intended to be a floor, not
the norm.
We conducted extensive data analysis, which included unit analysis,
revenue code and HCPCS/CPT frequency analysis, and we have learned that
PHPs often use the least costly staff and may not offer the full range
of PHP services contemplated in section 1861(ff) of the Act. However,
we believe the data accurately represent the level of service provided.
Because partial hospitalization is provided in lieu of inpatient
care, it should be a highly structured and clinically-intensive
program, usually lasting most of the day. Our goal is to improve the
level of service furnished in a PHP day. We are concerned that the
proposed decrease in PHP payment may not reflect the mix and quantity
of services that should be provided under such an intensive program. In
an effort to ensure access to this needed service to vulnerable
populations, we are mitigating the reduction to 50 percent of the
difference between the current APC amount ($233) and the computed
amount based on the PHP data ($172), resulting in an APC median cost of
$203. We believe this payment amount will give the providers an
opportunity to increase the intensity of their programs and maintain
partial hospitalization as part of the continuum of mental health care.
We reiterate our expectation that hospitals and CMHCs will provide
a comprehensive program consistent with the statutory intent. We intend
to explore the changes to our regulations and claims processing systems
in order to deny payment for low intensity days and we specifically
invite public comment on the most appropriate threshold.
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: As discussed earlier in this section, we have refined our
methodology for computing per diem costs. We have developed an
alternate way to determine median cost by computing a separate per diem
cost for each day rather than for each bill. Under this method, a cost
is computed separately for each day of PHP care. When there are
multiple days of care entered on a claim, a unique cost is computed for
each day of care. We only assign costs for line items on days when a
payment is made. All of these costs are then arrayed from lowest to
highest and the middle value of the array would be the median per diem
cost.
We adopted this alternative method of computing PHP per diem median
cost because we believe it produces a more accurate estimate because
each day gets an equal weight towards computing the median. This method
for computing a PHP per diem median cost more accurately reflects the
costs of a PHP and uses all available PHP data. Additionally, if a
provider has charges on a bill for which the provider does 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 changed by $2.00. As such,
we do not believe the calculations are adversely affected by the
inclusion of these days.
Comment: One commenter suggested that CMS set the PHP median per
diem cost based on days when four or more services are provided and
then pay a low-utilization payment adjustment amount for days when
three or fewer
[[Page 66674]]
services are provided. The commenter also suggested that CMS establish
frequency constraints for billing three or fewer services to prevent
the bulk of days furnished by a provider from becoming low utilization
days. The commenter urged CMS to further research this suggestion as a
possible payment restructuring for CY 2009. Several commenters urged
CMS to reevaluate the PHP payment methodology and to either refine the
APC structure for PHP to reflect different service levels or to exclude
the low-volume days from the calculation of the PHP rate and develop an
alternate payment policy for low-volume days.
Response: The structure of partial hospitalization is a full day of
treatment. We are concerned about providing an incentive for providers
to structure their PHPs on a half-day basis. As discussed earlier in
this section, in an effort to ensure access to this needed service to
vulnerable populations, we are mitigating the reduction to the PHP rate
for CY 2008. We think establishing a half-day rate is inconsistent with
this policy. Therefore, we are not prepared to establish a half day
rate at this time. However, we are willing to explore how we could
utilize frequency controls to maintain the overall intensity of the
partial hospitalization benefit.
Comment: One commenter noted that CMS did not respond to previous
statements from commenters that the industry would welcome
accreditation rules and/or stricter policies for PHPs.
Response: For the CY 2009 OPPS update, we are exploring proposing
conditions of participation for CMHCs to establish minimum standards
for patient rights, physical environment, staffing, and documentation
requirements. In addition, we are considering changes that are
necessary to our regulations and claims processing systems to deny
payment for low intensity days. We specifically invite public comment
on the most appropriate threshold.
Comment: Many commenters requested that the CMHC cost report data
be included in the HCRIS so that the industry can review and analyze
CMHC cost data.
Response: We understand the commenters' need to have CMHC data
available through the HCRIS system and are working to accomplish this
task.
Comment: With respect to the methodology used to establish the PHP
APC amount, commenters were concerned that data from settled cost
reports do not include costs reversed on appeal. The commenters stated
that there are inherent problems in using claims data from a time
period that is different from that for the CCRs from settled cost
reports. The commenters indicated this methodology would artificially
lower the computed median costs, and that the data used to calculate
the PHP rate should be revised to include costs that were subsequently
allowed. The commenters also stated that CMS uses costs that are at
least 1 to 3 years old to project rates 2 years forward and that this
approach does not accurately reflect the true costs of the providers.
Response: We use the best available data in computing the APCs. On
January 17, 2003, we issued Program Memorandum No. A-03-004 that
directed fiscal intermediaries to update the CCRs on an on going basis
whenever a more recent full year settled or tentatively settled 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 for
ratesetting purposes.
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 $64.45=$257.80). Another commenter
presented two different typical days using proposed CY 2008 rates.
Typical Day 1 included three Group Therapy sessions (CPT code 90853,
APC 0325, 3 x $64.45) and one Individual Psychotherapy session (CPT
code 90818, APC 0323, $106.49). The commenter priced Typical Day 1 at
$299.84. Typical Day 2 included one Group Therapy session (CPT code
90853, APC 0325, $64.45), one Individual Psychotherapy session (CPT
code 90818, APC 0323, $106.49), and one Family Therapy session (CPT
code 90847, APC 0324, $141.61). The commenter priced Typical Day 2 at
$312.55. Based on the commenter's presented material, the commenter
stated that the typical days yield an average componentized rate of
$306. The commenter questioned how CMS can set rates for APCs 0322
through 0325, but is unable to determine a payment rate for a day that
is comprised of a minimum of three to four of those services. Other
commenters stated that while CMS requires a minimum of four treatments
per day to qualify for a day of PHP, the proposed per diem rate of
$179.88 for PHP is less than what CMS would pay for four Group Therapy
sessions.
Response: We do not believe this is an appropriate comparison. The
commenter does not use the payment rate for the PHP APC, that is, APC
0033, in the calculations. 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 (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.
CMS examined both CMHC and hospital-based PHP program data to
determine what services these programs are providing to their patients.
An important finding was that the days cited by the commenter are not
typical days for most CMHCs. For CMHCs, 60 percent of services are
Group Psychotherapy (CPTs 90853 and 90857), 26 percent of services are
Training and Education (HCPCS G0177), 12 percent are Activity Therapy
(HCPCS G0176), and only 1 percent of PHP days included Individual
Therapy (Brief or Extended, CPTs 90816 or 90818)).
The days cited by the commenter are not typical days for hospital-
based PHPs either. For hospital-based PHPs, 47 percent of services are
Group Psychotherapy (CPT codes 90853 and 90857), 27 percent of services
are Training and Education (HCPCS code G0177), 16 percent are Activity
Therapy (HCPCS code G0176), 3 percent are Occupational Therapy (HCPCS
code G0129), 2 percent of PHP days include Brief Individual
Psychotherapy (CPT code 90816), and only 1 percent of PHP days include
Extended Individual Therapy (CPT code 90818).
We note that the APCs for Training and Education (HCPCS code
G0177), Activity Therapy (HCPCS code G0176), and Occupational Therapy
(HCPCS code G0129) are not separately payable under the OPPS. They are
packaged services and only payable as part of a PHP day of care. In
CMHCs, Training and Education (HCPCS code G0177) and Activity Therapy
(HCPCS code G0176), account for 38 percent of PHP services. In
hospital-based PHPs, Training and Education and Activity Therapy
account for 43 percent of PHP services. In addition to not being
separately payable, these services may be provided to
[[Page 66675]]
patients by less costly staff than staff that provide Psychotherapy and
Occupational Therapy. Based on the mix of services provided on the
majority of PHP days, we believe the data used for setting the PHP
payment appropriately reflect the typical PHP day.
Comment: One commenter asked CMS to consider implementing a
reimbursement level for intensive outpatient program (IOP) services
because the commenter's State requires 3 hours of service for such
programs.
Response: While some private insurers and some State Medicaid
programs recognize IOP as a distinct benefit (like PHP), Medicare does
not. However, hospitals that provide IOP services may bill Medicare
under the OPPS for individual mental health services that are otherwise
covered and billable under the OPPS.
Comment: Several commenters claimed that the costs of CMHCs 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 as hospitals to share costs
among its programs as needed. Further, we believe hospital costs in
some areas, for example, capital and 24-hour maintenance costs, greatly
exceed comparable CMHC costs. Notably, we believe patient acuity across
hospital-based and CMHC PHPs should be the same, that is, the patients
would otherwise require inpatient psychiatric care regardless of
setting (see sections 1861(ff) and 1835(a)(2)(F) of the Act).
Comment: A few commenters expressed concern that the current
methodology used to calculate the daily rate does not capture all
relevant data nor does it reflect the actual cost to providers to
deliver these services. The commenters asked that CMS analyze the
mapping of revenue-codes-to-cost centers for CMHCs similar to the
analysis CMS completed for hospital-based programs and discussed in the
CY 2007 OPPS/ASC final rule with comment period (71 FR 68000). The
commenters indicated that CMHC PHP services have higher cost-to-charge
ratios than the overall CMHC cost-to-charge ratios.
Response: We are unable to conduct a revenue code mapping analysis
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 overall facility CCR from the outpatient provider-specific file.
Comment: Several commenters expressed concern that cost report data
frequently do not reflect bad debt expense for the entire year. The
commenters are concerned that these costs are not being considered in
the CMS data and severely short change the rate calculations.
Response: While, the bad debt policy is outside the scope of this
rule, we refer the commenter to Sec. 413.89 and the Provider
Reimbursement Manual Part I (PRM), Chapter 3, concerning our bad debt
requirements.
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
the cost of meals and transportation to and from programs. The
commenter stated that almost all programs offer transportation because
in most cases 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: One commenter requested that the same provisions given to
rural HOPDs also be given to rural CMHCs. Several commenters urged CMS
to reconsider the changes in funding for these programs, especially the
programs in rural areas.
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
CMHCs. In addition, although 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: A few commenters stated that hospitals that offer partial
hospitalization services should not be penalized for the instability in
data reporting of CMHCs. Many commenters requested that CMS require
that CMHCs improve their reporting or have that provider group face
economic consequences.
Response: As described earlier in this section, after extensive
analysis, we now believe we have determined the appropriate level of
cost for the type of services that are being provided by PHPs. This
analysis included an examination of revenue-to-cost center mapping,
refinements to the per diem methodology, and an in-depth analysis of
the number of units of service per day. We note that for CY 2006, the
hospital-based PHPs per diem median cost is $177 and for CMHCs, the per
diem median cost is $172. We have observed a stabilizing trend in CMHC
data and similar per diem costs between hospital-based and CMHC PHPs.
Comment: Two national behavioral health care organizations
expressed concern that contrary to congressional intent, the most
intensive provider settings are being penalized. The commenters pointed
out that CMS data show that PHP programs providing four or more units
of service per day (programs that are highly intensive) have a
substantially higher median cost for those days than the overall median
cost per day. The commenters pointed out that hospital-based programs
(66 percent of their days have 4 or more units of service) have a
median cost of $218 versus a median cost of $186 for all days
regardless of the number of units of service. They noted that CMS' use
of the overall median cost per day understates the degree to which
hospital-based programs are structured around four or more units of
services, but acknowledge that on some days a patient may only get
three services (due to leaving early for illness, transitioning out of
the program, or other reasons). Similarly, according to one commenter,
CMHCs have a median cost of $191 for those days with 4 or more units of
service provided versus a median cost of $178 for all days. The
commenter stated that CMHCs have 36 percent of their days with 4 or
more units of service provided. The commenter indicated that its
State's Medicaid program requires a minimum of four hours to qualify
for a day of PHP and believed the CMS payment methodology is in
conflict with its State's laws.
Several commenters stated that the CMS data, when it combines those
programs that offer 3 units with those that offer 4 or more units,
clearly
[[Page 66676]]
penalizes the programs that routinely offer 4 or more units.
Response: We refer the commenter to the table presented earlier in
this section that provides updated figures to the ones cited by the
commenter. We recognize that by definition, 50 percent of PHP days will
have per diem costs higher than the median per diem cost, while 50
percent will have costs lower than the median per diem cost. It is
likely that the programs providing 4 units of service are on the high
side of the median per diem cost. In addition, we note that the final
rate of $203 is well above the combined median per diem cost for days
with 4 units of service of more ($192). Days where four services are
provided are certainly within this amount.
Comment: One commenter asked that CMS change the Medicare lifetime
maximum of 190 mental health days of stay in a psychiatric hospital, to
unlimited. The commenter asserted that if a person is diagnosed with a
mental health illness of various kinds the individual will need
``maintenance'' throughout his or her entire life.
Response: The 190-day lifetime limit on inpatient psychiatric care
is statutory, and established in section 1812(b)(3) of the Act.
Comment: Many commenters, including a national behavioral health
association, recommended that PHP be removed from the APC codes and
created under an independent status using home health and hospice as
examples. The commenters are concerned that the current methodology is
not conducive to this APC code and asserted that there is precedent in
other CMS OPPS service industries to exclude the service from the APC
code listing and treat it independently.
Response: 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 that implement this provision specify that payments under
the OPPS will be made for partial hospitalization services furnished by
CMHCs as well as those furnished to hospital outpatients and thus, PHP
is paid under the OPPS. However, it would require a statutory change to
establish an independent payment system for partial hospitalization
programs outside the OPPS. The statute provides specific separate and
distinct payment systems for both home health and hospice services,
which are also separate and distinct benefit categories.
Comment: One commenter asked why there are no CMHCs shown in the
impact statements in the annual OPPS updating documents published in
the Federal Register. 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 of
PHP days provided by CMHCs stays the same as it was in CY 2006, the
estimated impact on CMHCs as a result of the CY 2008 PHP payment rate
compared to the CY 2007 PHP payment rate is a 13-percent decrease. In
this year's impact table we have included CMHCs in the total count of
providers, but they are not shown separately. (For additional
information, see section XXIV, ``Regulatory Impact Analysis'' of this
final rule with comment period.)
Comment: Several commenters suggested establishing a PHP rate
calculation 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 commenter recommended that the ratesetting task force
be composed of CMS staff and a diverse group of stakeholder that
include front-line providers of PHP services and representatives from
national industry organizations. Other commenters requested that CMS
further study the possibility of differentiating payment based on the
intensity of services provided during a day of PHP services for CY
2009. These commenters also recommended that CMS establish quality
criteria to judge performance and that would influence future rate
reimbursement.
Response: We agree that the payment rate for PHP needs to be
accurate and appropriate to sustain access to care. While we believe we
provide an accurate and appropriate approach to payment for PHP, as
changes to the current methodology are considered, 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 would also find information about the status of quality
criteria useful and would encourage providers to submit that
information as well.
Comment: A few commenters stated that the wage index adjustment
does not accurately reflect the cost of labor in areas affected by
Hurricanes Katrina and Rita. The commenters also pointed out that the
proposed wage index in Louisiana has decreased post-hurricane instead
of increasing, which has resulted in a much lower payment rate in
Louisiana. The commenters further stated that the time lag for wage
indexing is a huge factor for Hurricane Zone providers and that the
wage index decrease makes the assumption that the cost of labor has
actually decreased since the hurricanes. Some commenters noted that the
lack of facilities, trained professionals and inadequate reimbursement
will make Louisiana worse off now than prior to Hurricanes Katrina and
Rita. A few commenters asked that CMS freeze the 2005 level rates to
maintain the Hurricane Zones at status quo until a realistic impact
study can be commissioned.
Response: The hospital wage data used to compute the IPPS FY 2008
hospital wage index is from the FY 2004 hospital cost reports for all
hospitals. This is the standard lag timeframe in determining the
hospital wage index. It will be another year before FY 2005 data will
be reflected in the IPPS FY 2009 hospital wage index. However, we note
that 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 the wage adjustments be made in
a budget neutral manner. Therefore, we cannot raise one wage area and
still maintain budget neutrality. Finally, it should be noted that
CMHCs located in Federal Emergency Management Agency (FEMA) designated
disaster areas were provided with relief funds by the Department of
Health and Human Services in 2007.
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
[[Page 66677]]
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, beginning in CY 2004, 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.
For CY 2007, we set the estimated outlier target at 1.0 percent and
allocated 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. The CY 2007 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 2007 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 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 noted in section II.G. of this final rule with comment period,
for CY 2008, 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 0.03 percent of outlier payments and 0.0003 percent of total
OPPS payments, would be allocated to CMHCs for PHP service outliers. As
discussed in section II.G. of this final rule with comment period, 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 2008 at 3.40 times the APC payment amount and the CY
2008 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 final rule with comment period, using more recent
data for this final rule with comment period, we set the target for
hospital outpatient outlier payments at 1.0 percent of total OPPS
payments. We allocate a portion of that 1.0 percent, an amount equal to
0.02 percent of outlier payments and 0.0002 percent of total OPPS
payments to CMHCs for PHP service outliers. For CY 2008, we set the
outlier threshold for CMHCs for CY 2008 at 3.40 times the APC payment
amount and the CY 2008 outlier percentage applicable to costs in excess
of the threshold at 50 percent.
C. Conversion Factor Update
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 2008, 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 final hospital market basket increase for FY 2008 published in
the IPPS final rule with comment period on August 22, 2007 is 3.3
percent (72 FR 48173), the same as the forecast published in the FY
2008 IPPS proposed rule on May 3, 2007 (72 FR 24787). To set the OPPS
conversion factor for CY 2008, we increased the CY 2007 conversion
factor of $61.468, as specified in the CY 2007 OPPS/ASC final rule with
comment period (71 FR 68003), by 3.3 percent.
In accordance with section 1833(t)(9)(B) of the Act, we further
adjusted the conversion factor for CY 2007 to ensure that the revisions
we are making to our updates for a revised wage index and rural
adjustment are made on a budget neutral basis. We calculated an overall
budget neutrality factor of 1.0019 for wage index changes by comparing
total payments from our simulation model using the FY 2008 IPPS final
wage index values as finalized to those payments using the current (FY
2007) IPPS wage index values. This adjustment reflected an adjustment
of 1.0001 for changes to the wage index and an additional 1.0018 to
accommodate the IPPS budget neutrality adjustment for inclusion of the
rural floor. As discussed further in section II.D. of this final rule
with comment period, for the first time, the final FY 2008 IPPS wage
indices included a blanket budget neutrality adjustment for including
the rural floor provision, which previously had been applied to the
IPPS standardized amount. For further discussion of this policy in its
entirety, we refer readers to the FY 2008 IPPS proposed rule (72 FR
24787 through 24792) and the FY 2008 IPPS final rule with comment
period (72 FR 47325 through 47330). This adjustment is specific to the
IPPS. For the OPPS, we are increasing the conversion factor by the
proportional amount of the rural floor budget neutrality adjustment to
accommodate this change.
For this final rule with comment period, we estimated the rural
adjustment for CY 2008 to reflect the extension of the adjustment to
payment for brachytherapy sources as discussed in section II.F.2. of
this final rule with comment period, but as the impact of the extension
was negligible, we did not change the rural adjustment. Therefore, we
calculated a budget neutrality factor of 1.000 for the rural
adjustment. For CY 2008, in this final rule with comment period, we
estimated that allowed pass through spending for both drugs and devices
would equal approximately $32 million, which represents 0.09 percent of
total OPPS projected spending for CY 2008. The conversion factor was
also adjusted by the difference between the 0.21 percent pass through
dollars set aside in CY 2007 and the 0.09 percent estimate for CY 2008
pass through spending. Finally, estimated payments for outliers remain
at 1.0 percent of total payments for CY 2008.
The market basket increase update factor of 3.3 percent for CY
2008, the required wage index and rural budget neutrality adjustment of
approximately 1.0019, and the adjustment of 0.12 percent for the
difference in the pass-through set aside resulted in a final standard
OPPS conversion factor for CY 2008 of $63.694.
We received one public comment on our proposed conversion factor
update for CY 2008. A summary of the public comment and our response
follow.
Comment: A commenter objected to the proposed market basket
increase of 3.3 percent. The commenter stated that the average
outpatient cost of service is projected to increase by at least 5
percent for CY 2008 due to increases in salaries and medical supply
costs for services to Medicare beneficiaries. The
[[Page 66678]]
commenter recommended that the average payment to hospitals for
outpatient services be increased by 5 percent, the actual amount by
which the commenter believed costs would increase for CY 2008.
Response: Section 1833(t)(3)(C)(iv) of the Act requires that CMS
update the conversion factor annually using an OPD fee schedule
increase factor specific to the PPS year. However, the statute gives
CMS the discretion to use the hospital inpatient update factor, the
hospital inpatient operating market basket, as an appropriate
substitute for the OPD fee schedule increase for purposes of the annual
percentage increase specific to covered OPD services. The statute
permits, and we continue to believe, that the hospital inpatient
operating market basket is an appropriate measure of change in hospital
input prices for goods and services required to provide hospital care,
including that in the outpatient setting. Hospitals use similar
resources in their hospital inpatient and outpatient departments. The
hospital market basket is carefully estimated for each PPS year, and
periodically rebased and revised. For these reasons, we have specified
in the regulations governing the annual OPPS update at Sec. 419.32
(b)(iv) that, for years beginning after CY 2003, the update factor for
the OPPS equals the update factor for the IPPS. We disagree that the
update factor for the CY 2008 OPPS should be 5 percent. For FY 2008,
the IPPS update factor is the hospital market basket of 3.3 percent
and, therefore, we have used this update factor in the establishment of
the conversion factor for the CY 2008 OPPS.
After consideration of the public comment received, we are
finalizing our CY 2008 proposal, without modification, to update the
conversion factor by the FY 2008 IPPS market basket increase update
factor of 3.3 percent, resulting in a final conversion factor of
$63.694.
D. Wage Index Changes
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, which includes the
copayment standardized amount, that is 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 the OPPS were attributable to wage costs. We
confirmed that this labor-related share for outpatient services is
still appropriate during our regression analysis for the payment
adjustment for rural hospitals in the CY 2006 OPPS final rule with
comment period (70 FR 68553). Therefore, we did not propose to revise
this policy for the CY 2008 OPPS. We refer readers to 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 final IPPS wage indices for the OPPS and to 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 final rule with comment
period, we standardize 60 percent of estimated costs as labor-related
costs for geographic area wage variation using the IPPS pre-
reclassified wage indices in order to remove the effects of differences
in area wage levels in determining the national unadjusted OPPS payment
rate and the copayment amount.
As published in the original OPPS April 7, 2000 final rule with
comment period (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. 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 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. In accordance with section 1886(d)(3)(E) of the Act,
the IPPS wage index is updated annually. In accordance with our
established policy, we proposed to use the final FY 2008 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 2008.
We note that the FY 2008 IPPS wage indices continue to reflect a
number of changes implemented over the past few years 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, wage adjustments
provided for under Pub. L. 105-33 and Pub. L. 108-173, and
clarification of our policy for multicampus hospitals. The following is
a brief summary of the components of the FY 2008 IPPS wage indices and
any adjustments that we are applying to the OPPS for CY 2008. We refer
the reader to the FY 2008 IPPS final rule with comment period (72 FR
47308 through 47345) for a detailed discussion of the changes to the
wage indices. In this final rule with comment period, we are not
reprinting the final FY 2008 IPPS wage indices referenced in the
discussion below, with the exception of the out migration wage
adjustment table (Addendum L to this final rule with comment period),
which includes non-IPPS providers paid under the OPPS. We also refer
readers to the CMS Web site for the OPPS at: http://www.cms.hhs.gov/
providers/hopps. At this link, the reader will find a link to the final
FY 2008 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 2008
IPPS final rule with comment period, we again stated that hospitals
located in Metropolitan Statistical Areas (MSAs) will be urban and
hospitals that are located in Micropolitan Areas or outside CBSAs will
be rural. We also reiterated our policy that when an MSA is divided
into one or more Metropolitan Divisions, we use the Metropolitan
Division for purposes of defining the boundaries of a particular labor
market area. 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. This hold harmless provision expired
after FY 2007. We adopted the same policy for the OPPS, but because the
OPPS operates on a calendar year, wage index policies are in effect
through December 31, 2007. To be consistent with the IPPS, as finalized
in the FY 2008 IPPS final rule with comment period, beginning in CY
2008 (January 1, 2008)
[[Page 66679]]
under the OPPS, these hospitals will receive their statewide rural wage
index. Hospitals paid under the IPPS are eligible to apply for
reclassification in FY 2008.
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 wage indices
identified in the FY 2008 IPPS final rule with comment period (and as
corrected in the September 28, 2007 second FY 2008 IPPS correction
notice that was printed in the October 10, 2007 Federal Register (72 FR
57634) that are fully adjusted for differences in occupational mix
using the entire 6-month survey data collected in 2006.
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 2008,
including reclassifications that the Medicare Geographic Classification
Review Board (MGCRB) approved. We note that reclassifications under
section 508 of Pub. L. 108-173 were set to terminate March 31, 2007.
However, section 106(a) of the MIEA-TRHCA extended any geographic
reclassifications of hospitals that were made under section 508 and
that would expire on March 31, 2007 until September 30, 2007. On March
23, 2007, we published a notice in the Federal Register (72 FR 13799)
that indicated how we are implementing section 106 of the MIEA-TRHCA
through September 30, 2007. Because the section 508 provision expired
on September 30, 2007, the OPPS wage index will not include any
reclassifications under section 508 for CY 2008.
3. The out-migration wage adjustment to the wage index. In the FY
2008 IPPS final rule with comment period (72 FR 473398 through 47341),
we discussed the out migration adjustment under section 505 of Pub. L.
108-173 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. We note that in the FY 2008 IPPS final rule with comment
period, we finalized our proposal to use the post-reclassified, rather
than the pre-reclassified, wage indices in calculating the out-
migration adjustment. (See the FY 2008 IPPS final rule with comment
period and the second FY 2008 IPPS correction notice for further
information on the out migration adjustment.) For OPPS purposes, we
proposed to continue our policy in CY 2008 to allow-non IPPS hospitals
paid under the OPPS to qualify for the 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. Table 4J published in the Addendum to the FY 2008 IPPS
final rule with comment period (and corrected in the second FY 2008
IPPS correction notice) identifies counties eligible for the out-
migration adjustment and providers receiving the adjustment. As stated
earlier, we are reprinting the final version of Table 4J, as corrected,
in this final rule with comment period as Addendum L.
4. Wage Index for Multicampus Hospitals. As indicated in the CY
2008 OPPS/ASC proposed rule (72 FR 42695), we also wish to clarify that
the IPPS policy for multicampus wage index payments also applies to the
OPPS. As a result of the new labor market areas introduced in FY 2005,
there are hospitals with multiple campuses previously located in a
single MSA that are now in more than one CBSA. A multicampus hospital
is an integrated institution. For this reason, the multicampus hospital
has one CMS certification number (CCN) and submits a single cost report
that combines the total wages and hours of each of its campuses in the
manner described in the FY 2008 IPPS final rule with comment period (72
FR 47317).
In the FY 2008 IPPS final rule with comment period, we finalized
our proposal to apportion wages and hours across multiple campuses
using full-time equivalent (FTE) staff data or Medicare discharge data
in order to include wage data for the individual campuses of a
multicampus hospital in its local wage index calculation. We indicated
our intent to collect campus locations and numbers of FTE staff by
location by adding lines to Worksheet S-2 of the Medicare cost report
submitted by hospitals. We stated that we would continue to use either
Medicare discharge data or self-reported FTE data to apportion wage
data by campus until revisions are made to Worksheet S-2 of the
Medicare cost report to require reporting of FTE data by campus and
until such data in the cost report can be used to calculate the wage
index, at which time the wage data of a multicampus hospital will be
allocated among its campuses based only on FTE counts by campus
reported in the Medicare cost report. We stated that the effective date
of the revised cost report is not expected until FY 2009. Therefore the
FTE data reported by multicampus hospitals in the revised Medicare cost
report could not be used to allocate wages and hours to each labor
market by FTEs until at least the FY 2013 wage index. As part of this
policy, we would fully expect that an HOPD that is part of a
multicampus hospital system would receive a wage index based on the
geographic location of the inpatient campus with which it is
associated. This would include cases where one inpatient campus
reclassified. Affiliated outpatient facilities would receive the
reclassified wage index of the inpatient campus. For further discussion
of the FY 2008 IPPS final multicampus hospital policy in its entirety,
we refer readers to the FY 2008 IPPS final rule with comment period (72
FR 47317 through 47319).
5. Rural Floor Provision. Section 4410 of Pub. L. 105-33 provides
that the area wage index applicable to any hospital that is located in
an urban area of a State may not be less than the area wage index
applicable to hospitals located in rural areas of the State (``the
rural floor''). Table 4A in the FY 2008 IPPS final rule with comment
period (72 FR 47503) (and as corrected in the September 28, 2007 second
correction notice for the FY 2008 IPPS final rule, which appeared in
the October 10, 2007 issue of the Federal Register) identifies urban
areas where hospitals located in those areas are assigned the rural
floor (noted by a superscript ``2''). For CY 2008 under the OPPS, we
proposed to continue our policy to allow non-IPPS hospitals paid under
the OPPS to receive the rural floor wage index, when applicable under
the IPPS for FY 2008. For the first time, the final FY 2008 IPPS wage
indices include a blanket budget neutrality adjustment for including
the rural floor provision, which previously had been applied to the
IPPS standardized amount. For further discussion of this final policy
in its entirety, we refer readers to the FY 2008 IPPS final rule with
comment period (72 FR 47325 through 47330) and the second FY 2008 IPPS
correction notice (72 FR 57634).
We note that 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 2008 in this
final rule with comment period, we have included the wage index changes
that would result from the MGCRB reclassifications, implementation of
sections 4410 of Pub. L. 105-33 and 505 of Pub. L. 108-173, and other
refinements adopted in the FY 2008 IPPS final rule with comment period.
For the CY 2008 OPPS, we proposed to use the final FY 2008 IPPS
[[Page 66680]]
wage indices, including the budget neutrality adjustment for the rural
floor, for calculating OPPS payment in CY 2008. We discuss how the OPPS
conversion factor would compensate for the inclusion of this budget
neutrality adjustment in the wage indices in section II.C. of this
final rule with comment period relating to the conversion factor
update.
Comment: Commenters supported the CMS proposal for CY 2008 to
extend the IPPS wage indices to the OPPS as we had done in previous
years. One commenter agreed with the proposal to adopt the IPPS wage
index but suggested that it would be logical to adopt the same labor
component percentage as applied under the IPPS. The commenter argued
that the labor component is derived from hospital cost report
information that does not separate inpatient from outpatient services
for labor-related and nonlabor-related costs, and thus the labor
component utilized in the IPPS is based on a combination of inpatient
and outpatient costs. The commenter also suggested that the 60 percent
labor-related share used in the OPPS was derived nearly 10 years ago
and has never been supported by analysis. The commenter recommended
that CMS revise the labor-related share from 60 percent to 69.731
percent to be consistent with the IPPS.
Response: We appreciate the support expressed by commenters
concerning our proposed wage index policies for CY 2008. In response to
the comment concerning the OPPS labor-related share, we do not believe
that such a change to adopt the IPPS labor related share is
appropriate. The current IPPS labor-related share of 69.731 percent was
calculated by summing the relative weights for labor components in the
IPPS operating market basket (70 FR 2339). The IPPS estimates a labor-
related share that is specific to inpatient services; the OPPS
estimates a labor-related share that is specific to outpatient
services. The OPPS labor-related share was determined through
regression analyses conducted for the initial OPPS proposed rule (63 FR
47581). Those analyses examined the extent of variability in hospital
outpatient cost per unit explained by variability in the wage index,
holding outpatient service mix under the proposed system, geographic
location, volume, and other variables constant. The unit cost dependent
variable in these analyses was derived by applying the CCRs for
ancillary cost centers to charges, and those ancillary CCRs should
reflect the proportional labor costs for ancillary services. The wage
index provides a measure of the wage level faced by a hospital relative
to the national average, which should be roughly the same for the
institution across inpatient and outpatient settings. Those initial
analyses identified 60 percent as the appropriate labor-related share
for outpatient services. We confirmed that this labor-related share is
still appropriate during our regression analysis for the payment
adjustment for rural hospitals, as discussed in the CY 2006 OPPS final
rule with comment period (70 FR 68556). Further, we would expect
services delivered in the HOPD to require proportionately less labor
than more acute inpatient services that require greater nursing care
and an extended stay. We believe that the 60 percent labor-related
share for the OPPS compares favorably to the hospital inpatient labor-
related share of 69.731 percent.
We are finalizing our proposal, without modification, to use the
final IPPS FY 2008 wage indices to adjust the OPPS standard payment
amounts for labor market differences under the CY 2008 OPPS.
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 2007 in
our final rule with comment period (71 FR 68006 through 68009). As we
proposed, in this final rule with comment period we have updated the
default ratios for CY 2008 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. Table 25
published in the CY 2008 OPPS/ASC proposed rule listed the proposed CY
2008 default urban and rural CCRs by State and compared them to last
year's default CCRs. 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 ratios from submitted cost reports to
reflect final settled status by applying the differential between
settled to submitted costs and charges from the most recent pair of
final settled and submitted cost reports.
For the proposed rule, approximately 78 percent of the submitted
cost reports represented data for CY 2005. We have since updated the
cost report data we use to calculate CCRs with additional submitted
cost reports for CY 2006. For this final rule with comment period, 47
percent of the submitted cost reports utilized in the default ratio
calculation were for CY 2005 and 49 percent were for CY 2006. 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, American Samoa, and the Northern Mariana
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 2006.
Finally, we calculated an overall average CCR, weighted by a
measure of volume for CY 2006, 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. 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 and this year's default statewide CCRs largely reflect a general
decline in the ratio between costs and charges widely observed in the
cost report data. However, observed increases in some areas suggest
that the decline in CCRs is moderating. Further, the addition of
weighting by Medicare Part B charges to the overall CCR in CY 2007
slightly increases the variability of the 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.
Prior to CY 2007, OPPS policy required hospitals that experienced a
change of ownership, but that did not accept assignment of the previous
hospital's provider agreement, to use the
[[Page 66681]]
previous provider's CCR. However, in CY 2007 we revised this policy and
finalized our proposal to use default statewide CCRs for entities that
had not accepted assignment of an existing hospital's provider
agreement in accordance with Sec. 489.18 and that had not yet
submitted its first Medicare cost report. For CY 2008, we proposed to
continue 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. This policy is
effective for hospitals experiencing a change of ownership on or after
January 1, 2007. As stated in the CY 2007 OPPS/ASC final rule with
comment period (71 FR 68006), 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 also 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 this issue.
Therefore, we are finalizing the statewide average default CCRs as
shown in Table 11 below for OPPS services furnished on or after January
1, 2008, without modification.
Table 11.--CY 2008 Statewide Average CCRs
----------------------------------------------------------------------------------------------------------------
Previous
CY 2008 default CCR
State Rural/urban default CCR (CY 2007 OPPS
final rule)
----------------------------------------------------------------------------------------------------------------
ALASKA..................................... RURAL.............................. 0.537 0.534
ALASKA..................................... URBAN.............................. 0.351 0.383
ALABAMA.................................... RURAL.............................. 0.228 0.232
ALABAMA.................................... URBAN.............................. 0.213 0.223
ARKANSAS................................... RURAL.............................. 0.266 0.264
ARKANSAS................................... URBAN.............................. 0.270 0.275
ARIZONA.................................... RURAL.............................. 0.264 0.282
ARIZONA.................................... URBAN.............................. 0.232 0.232
CALIFORNIA................................. RURAL.............................. 0.232 0.246
CALIFORNIA................................. URBAN.............................. 0.218 0.232
COLORADO................................... RURAL.............................. 0.355 0.370
COLORADO................................... URBAN.............................. 0.254 0.267
CONNECTICUT................................ RURAL.............................. 0.391 0.389
CONNECTICUT................................ URBAN.............................. 0.339 0.349
DISTRICT OF COLUMBIA....................... URBAN.............................. 0.346 0.339
DELAWARE................................... RURAL.............................. 0.302 0.323
DELAWARE................................... URBAN.............................. 0.400 0.395
FLORIDA.................................... RURAL.............................. 0.219 0.219
FLORIDA.................................... URBAN.............................. 0.198 0.199
GEORGIA.................................... RURAL.............................. 0.279 0.285
GEORGIA.................................... URBAN.............................. 0.269 0.289
HAWAII..................................... RURAL.............................. 0.373 0.357
HAWAII..................................... URBAN.............................. 0.317 0.320
IOWA....................................... RURAL.............................. 0.349 0.349
IOWA....................................... URBAN.............................. 0.325 0.343
IDAHO...................................... RURAL.............................. 0.445 0.436
IDAHO...................................... URBAN.............................. 0.414 0.416
ILLINOIS................................... RURAL.............................. 0.286 0.308
ILLINOIS................................... URBAN.............................. 0.271 0.288
INDIANA.................................... RURAL.............................. 0.313 0.316
INDIANA.................................... URBAN.............................. 0.301 0.320
KANSAS..................................... RURAL.............................. 0.318 0.320
KANSAS..................................... URBAN.............................. 0.240 0.252
KENTUCKY................................... RURAL.............................. 0.244 0.251
KENTUCKY................................... URBAN.............................. 0.262 0.270
LOUISIANA.................................. RURAL.............................. 0.271 0.281
LOUISIANA.................................. URBAN.............................. 0.277 0.273
MARYLAND................................... RURAL.............................. 0.308 0.318
MARYLAND................................... URBAN.............................. 0.284 0.298
MASSACHUSETTS.............................. URBAN.............................. 0.338 0.349
MAINE...................................... RURAL.............................. 0.433 0.457
MAINE...................................... URBAN.............................. 0.424 0.429
MICHIGAN................................... RURAL.............................. 0.331 0.346
MICHIGAN................................... URBAN.............................. 0.318 0.329
MINNESOTA.................................. RURAL.............................. 0.499 0.508
MINNESOTA.................................. URBAN.............................. 0.342 0.338
MISSOURI................................... RURAL.............................. 0.289 0.294
MISSOURI................................... URBAN.............................. 0.292 0.303
MISSISSIPPI................................ RURAL.............................. 0.267 0.284
MISSISSIPPI................................ URBAN.............................. 0.217 0.231
MONTANA.................................... RURAL.............................. 0.453 0.439
[[Page 66682]]
MONTANA.................................... URBAN.............................. 0.450 0.463
NORTH CAROLINA............................. RURAL.............................. 0.286 0.305
NORTH CAROLINA............................. URBAN.............................. 0.321 0.370
NORTH DAKOTA............................... RURAL.............................. 0.379 0.367
NORTH DAKOTA............................... URBAN.............................. 0.378 0.395
NEBRASKA................................... RURAL.............................. 0.347 0.376
NEBRASKA................................... URBAN.............................. 0.290 0.290
NEW HAMPSHIRE.............................. RURAL.............................. 0.375 0.370
NEW HAMPSHIRE.............................. URBAN.............................. 0.337 0.325
NEW JERSEY................................. URBAN.............................. 0.276 0.297
NEW MEXICO................................. RURAL.............................. 0.275 0.274
NEW MEXICO................................. URBAN.............................. 0.353 0.398
NEVADA..................................... RURAL.............................. 0.329 0.335
NEVADA..................................... URBAN.............................. 0.200 0.214
NEW YORK................................... RURAL.............................. 0.417 0.445
NEW YORK................................... URBAN.............................. 0.402 0.427
OHIO....................................... RURAL.............................. 0.354 0.369
OHIO....................................... URBAN.............................. 0.268 0.283
OKLAHOMA................................... RURAL.............................. 0.288 0.295
OKLAHOMA................................... URBAN.............................. 0.245 0.261
OREGON..................................... RURAL.............................. 0.321 0.344
OREGON..................................... URBAN.............................. 0.366 0.405
PENNSYLVANIA............................... RURAL.............................. 0.298 0.305
PENNSYLVANIA............................... URBAN.............................. 0.241 0.252
PUERTO RICO................................ URBAN.............................. 0.474 0.469
RHODE ISLAND............................... URBAN.............................. 0.308 0.309
SOUTH CAROLINA............................. RURAL.............................. 0.258 0.255
SOUTH CAROLINA............................. URBAN.............................. 0.244 0.248
SOUTH DAKOTA............................... RURAL.............................. 0.334 0.348
SOUTH DAKOTA............................... URBAN.............................. 0.289 0.304
TENNESSEE.................................. RURAL.............................. 0.256 0.265
TENNESSEE.................................. URBAN.............................. 0.241 0.249
TEXAS...................................... RURAL.............................. 0.271 0.289
TEXAS...................................... URBAN.............................. 0.242 0.258
UTAH....................................... RURAL.............................. 0.416 0.441
UTAH....................................... URBAN.............................. 0.406 0.416
VIRGINIA................................... RURAL.............................. 0.268 0.282
VIRGINIA................................... URBAN.............................. 0.275 0.280
VERMONT.................................... RURAL.............................. 0.416 0.432
VERMONT.................................... URBAN.............................. 0.340 0.338
WASHINGTON................................. RURAL.............................. 0.358 0.374
WASHINGTON................................. URBAN.............................. 0.368 0.372
WISCONSIN.................................. RURAL.............................. 0.384 0.367
WISCONSIN.................................. URBAN.............................. 0.362 0.364
WEST VIRGINIA.............................. RURAL.............................. 0.298 0.316
WEST VIRGINIA.............................. URBAN.............................. 0.360 0.369
WYOMING.................................... RURAL.............................. 0.449 0.471
WYOMING.................................... URBAN.............................. 0.351 0.352
----------------------------------------------------------------------------------------------------------------
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 (called either transitional
corridor payment or transitional outpatient payment) if the payments it
received for covered outpatient department (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 to ease their transition from
the prior reasonable cost-based payment system to the OPPS system.
There are two exceptions, cancer hospitals and children's hospitals, to
this provision and those 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 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 ended on December 31, 2005. Accordingly, the
authority for making transitional corridor payments under
[[Page 66683]]
section 1833(t)(7)(D)(i) of the Act, as amended by section 411 of Pub.
L. 108-173, for rural hospitals having 100 or fewer beds and SCHs
located in rural areas expired 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 between the
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 implemented section 5105 of Pub. L. 109-171 through
Transmittal 877, issued on February 24, 2006. We did not specifically
address whether TOPs 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 believed and continue to
believe that EACHs are not currently eligible for TOPs under Pub. L.
109-171. However, they are eligible for the adjustment for rural SCHs.
In the CY 2007 OPPS/ASC final rule with comment period, we updated
Sec. 419.70(d) to reflect the requirements of Pub. L. 109-171 (71 FR
68010 and 68228).
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 for rural SCHs. Therefore, we
implemented a payment adjustment for only those hospitals beginning
January 1, 2006.
Last year, we 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. Therefore, in the CY 2007 OPPS/ASC
final rule with comment period, for purposes of receiving this rural
adjustment, we revised Sec. 419.43(g) to clarify that EACHs are also
eligible to receive the rural SCH adjustment, assuming these entities
otherwise meet the rural adjustment criteria (71 FR 68010 and 68227).
Currently, fewer than 10 hospitals are classified as EACHs and as of CY
1998, under section 4201(c) of Pub. L. 105-33, a hospital can no longer
become newly classified as an EACH.
This adjustment for rural SCHs is budget neutral and applied before
calculating outliers and copayment. As stated in the CY 2006 OPPS final
rule with comment period (70 FR 68560), we would not reestablish the
adjustment amount on an annual basis, but we note that we may review
the adjustment in the future and, if appropriate, would revise the
adjustment.
For CY 2008, we proposed to continue our current policy of a budget
neutral 7.1 percent payment increase for rural SCHs, including EACHs,
for all services and procedures paid under the OPPS, excluding drugs,
biologicals, and services paid under the pass-through payment policy in
accordance with section 1833(t)(13)(B) of the Act. This adjustment is
in accordance with section 411 of the MMA, which gave the Secretary the
authority to make an adjustment to OPPS payments for rural hospitals,
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. For CY 2008, we also
proposed to include brachytherapy sources in the group of services
eligible for the 7.1 percent payment increase because we proposed to
pay them at prospective rates based on their median costs as calculated
from historical claims data. Consequently, we proposed to revise Sec.
419.43 to reflect our proposal to make brachytherapy sources eligible
for the 7.1 percent payment increase for rural SCHs. As indicated in
our proposed rule (72 FR 42698), we intend to reassess the 7.1 percent
adjustment in the near future by examining differences between urban
and rural costs using updated claims, cost, and provider information.
In that process, we will include brachytherapy sources in each
hospital's mix of services.
Comment: Several commenters supported our proposals to continue our
current policy of a budget neutral 7.1 percent payment increase for
rural SCHs, including EACHs, for all services and procedures paid under
the OPPS, excluding drugs, biologicals, and services paid under the
pass-through payment policy, and to make brachytherapy sources eligible
for the 7.1 percent payment increase for rural SCHs.
Response: We appreciate the commenters' support of the policy.
After consideration of the public comments received, we are
finalizing, without modification, our policy to continue a payment
adjustment for rural SCHs, including EACHs, of 7.1 percent for CY 2008.
We also are finalizing our proposed revision of Sec. 419.43 to make
brachytherapy sources eligible for the 7.1 percent payment increase for
rural SCHs, including EACHs, without modification.
G. Hospital Outpatient Outlier Payments
1. Background
Currently, the OPPS pays outlier payments on a service-by-service
basis. For CY 2007, 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 $1,825
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.
As explained in the CY 2007 OPPS/ASC final rule with comment period
(71 FR 68011 through 68012), we set our projected target for aggregate
outlier payments at 1.0 percent of aggregate total payments under the
OPPS for CY 2007. The outlier thresholds were set so that estimated CY
2007 aggregate outlier payments would equal 1.0 percent of aggregate
total payments under the OPPS. In that final rule with comment period
(71 FR 68010) we also published total outlier payments as a percent of
total expenditures for CY 2005. In the past, we have received comments
asking us to publish estimated outlier payments to provide a context
for the proposed outlier thresholds for the update year. In the CY 2008
OPPS/ASC
[[Page 66684]]
proposed rule (72 FR 42698), we estimated, using available CY 2006
claims, that the outlier payments for CY 2006 would be approximately
1.1 percent of total CY 2006 OPPS payment. In the final CY 2006 claims,
aggregated outlier payments were 1.1 percent of aggregated total OPPS
payments. For CY 2006, the estimated outlier payments were set at 1.0
percent of the total aggregated OPPS payments. Therefore, for CY 2006
we paid 0.1 percent in excess of the CY 2006 outlier target of 1.0
percent of total aggregated OPPS payments. Using the final CY 2006
claims and CY 2007 payment rates, we currently estimate that outlier
payments for CY 2007 would be approximately 0.7 percent of total CY
2007 OPPS payments and the difference between 1.0 percent and 0.7
percent is reflected in the regulatory impact analysis in section
XXIV.B. of this final rule with comment period. We will not know the
final amount of outlier payments as a percent of total payments until
we have final CY 2007 claims. We note that we provide estimated CY 2008
outlier payments by hospital for hospitals with claims included in the
claims data that we used to model impacts on the CMS Web site in the
Hospital--Specific Impacts--Provider-Specific Data file on the CMS Web
site at: http://www.cms.hhs.gov/HospitalOutpatientPPS/.
2. Proposed Outlier Calculation
For CY 2008, we proposed to continue our policy of setting aside
1.0 percent of aggregate total payments under the OPPS for outlier
payments. We proposed that a portion of that 1.0 percent, 0.03 percent,
would be allocated to CMHCs for partial hospitalization program service
outliers. This amount is the amount of estimated outlier payments
resulting from the proposed CMHC outlier threshold of 3.4 times the APC
payment rate, as a proportion of all payments dedicated to outlier
payments. For this final rule, we estimate that 0.02 percent of total
outlier payments would be allocated to CMHC's for partial
hospitalization program service outliers. For further discussion of
CMHC outliers, we refer readers to section II.B.3. of this final rule
with comment period.
In order to ensure that estimated CY 2008 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 $2,000 fixed-dollar
threshold. This proposed threshold reflected minor changes to the
methodology discussed below as well as APC recalibration, including
changes due in part to the CY 2008 packaging approach discussed in
section II.A.4.c. of this final rule with comment period.
We calculated the fixed-dollar threshold for the CY 2008 proposed
rule using largely the same methodology as we did in CY 2007, except
that we proposed to adjust the overall CCRs to reflect the anticipated
annual decline in overall CCRs, discussed below, and to use CCRs from
the most recent update to the Outpatient Provider-Specific File (OPSF),
rather than CCRs we calculate internally for ratesetting. As noted in
the CY 2008 OPPS/ASC proposed rule (72 FR 42699), in November 2006 we
issued Transmittal 1030, ``Policy Changes to the Fiscal Intermediary
(FI) Calculation of Hospital Outpatient Payment System (OPPS) and
Community Mental Health Center (CMHC) Cost to Charge Ratios (CCRs),''
instructing fiscal intermediaries (or, if applicable, MACs) to update
the overall CCR calculation for outlier and other cost-based payments
using the CCR calculation methodology that we finalized for CY 2007. As
discussed in the CY 2007 OPPS/ASC proposed rule and final rule with
comment period, this methodology aligned the fiscal intermediary's CCR
calculation and the CCR calculation we previously used to model outlier
thresholds 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'' CCR
calculation by total Medicare Part B charges. We believe that the OPSF
best estimates the CCRs that fiscal intermediaries (or, if applicable,
MACs) would use to determine outlier payments in CY 2008. For the
proposed rule, we used the April update to the OPSF. We supplemented a
CCR calculated internally for the handful of providers with claims in
our claims dataset that were not listed in the April update to the
OPSF.
The claims that we use to model each OPPS update lag by 2 years.
For the proposed rule, we used CY 2006 claims to model the CY 2008
OPPS. In order to estimate CY 2008 outlier payments for the proposed
rule, we inflated the charges on the CY 2006 claims using the same
inflation factor of 1.1504 that we used to estimate the IPPS fixed-
dollar outlier threshold for the FY 2008 IPPS proposed rule. For 1
year, the inflation factor is 1.0726. The methodology for determining
this charge inflation factor was discussed in the FY 2008 IPPS proposed
rule (72 FR 24837) and in the FY 2008 IPPS final rule with comment
period (72 FR 47417). 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).
In comments on the CY 2007 OPPS/ASC proposed rule, a 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
indicated that it would be appropriate to apply an inflation adjustment
factor so that the CCRs that CMS uses to simulate OPPS outlier payments
would more closely reflect the CCRs that would be used in CY 2007 to
determine actual outlier payment. In the CY 2007 OPPS/ASC final rule
with comment period, we expressed concern that cost increases between
inpatient and outpatient departments could be different and indicated
that we would study the issue and address any changes to the outlier
methodology through future rulemaking (71 FR 68012).
In assessing the possibility of utilizing a cost inflation
adjustment for the OPPS, we determined that we could not calculate an
OPPS-specific reliable cost per unit, comparable to the cost per
discharge component of the IPPS calculation, because of variability in
definition of an OPPS unit of service across calendar years. However,
we also believed that the costs and charges reported under the
applicable cost centers largely are commingled inpatient and outpatient
costs and charges. We did not want to systematically overestimate the
OPPS outlier threshold as could occur if we did not apply a CCR
inflation adjustment factor. Therefore, we proposed to apply the CCR
adjustment factor that was proposed to be applied for IPPS outlier
calculation to the CCRs used to simulate the CY 2008 OPPS outlier
payments that determined the fixed-dollar threshold. Specifically, for
CY 2008, we proposed to apply an adjustment of 0.9912 to the CCRs that
are currently on the OPSF to trend them forward from CY 2007 to CY
2008. The methodology for calculating this adjustment is discussed in
the FY 2008 IPPS proposed rule (72 FR 24837) and the FY 2008 IPPS final
rule with comment period (72 FR 47417).
[[Page 66685]]
Therefore, for the CY 2008 proposed rule, we applied the overall
CCRs from the April 2007 OPSF file after adjustment to approximate CY
2008 CCRs (using the proposed CCR inflation adjustment factor of
0.9912) to charges on CY 2006 claims that were adjusted to approximate
CY 2008 charges (using the proposed charge inflation factor of 1.1504).
We simulated aggregated CY 2008 outlier payments using these costs for
several different fixed-dollar thresholds, holding the 1.75 multiple
constant and assuming that outlier payment would continue to be made at
50 percent of the amount by which the cost of furnishing the service
would exceed 1.75 times the APC payment amount, until the total outlier
payments equaled 1.0 percent of aggregated estimated total CY 2008 OPPS
payments. We estimated that a proposed fixed-dollar threshold of
$2,000, combined with the proposed multiple threshold of 1.75 times the
APC payment rate, would allocate 1.0 percent of aggregated total OPPS
payments to outlier payments. We proposed to continue to make an
outlier payment that equals 50 percent of the amount by which the cost
of furnishing the service exceeds 1.75 times the APC payment amount
when both the 1.75 multiple threshold and the fixed-dollar $2,000
threshold are met. For CMHCs, if a CMHC provider's cost for partial
hospitalization exceeds 3.4 times the payment rate for APC 0033, the
outlier payment is calculated as 50 percent of the amount by which the
cost exceeds 3.4 times the APC payment rate.
We received several public comments related to this proposal. A
summary of the public comments and our responses follow.
Comment: Several commenters requested that CMS publish annual
outlier payments as a percentage of total OPPS payment.
Response: We currently publish the total outlier payments as a
percent of total payment for past years in the annual OPPS/ASC proposed
and final rules. We have projected outlier payments to be 1.1 percent
of total OPPS payments for CY 2006, the most complete set of full year
claims data that currently exists. We plan to continue to publish these
numbers for future years, after we have full year cost data. For CY
2008, we estimate that outlier payments will be 1.0 percent of total
payment.
Comment: One commenter agreed with our proposal to raise the fixed
dollar outlier threshold accordingly so that the 1.0 percent target for
outlier payments is met. Other commenters requested that CMS lower the
fixed dollar threshold so that a greater number of services would be
eligible for outlier payments. One commenter noted that the proposed
increased fixed dollar threshold significantly reduced the number of
services that would be eligible for outlier payments. Another commenter
expressed concern that increased OPPS packaging would cause CMS to pay
less in outlier payments than in the past. Other commenters were
concerned that the fixed dollar outlier threshold that CMS proposed was
set too high and would result in CMS spending less money than allocated
for the projected 1.0 percent outlier target. These commenters argued
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 base OPPS rates or reduce the
threshold for qualification so that the outlier expenditures would be
at a zero balance at the end of each year. Several commenters 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 2008, that
the CY 2008 threshold would be increased by only 3.3 percent. Other
commenters suggested that the outlier payment be increased from 50
percent to 80 percent of the difference between the APC payment and the
cost of the service. They believed that this would more appropriately
account for the additional cost of the service and make the outlier
payment policy consistent with IPPS policy.
Response: Consistent with the views of most commenters, we are
reducing the proposed fixed dollar outlier threshold based on our
updated analysis for this final rule with comment period, where we use
the most current claims and cost report data and final payment policies
to estimate the threshold that would allow us to pay CY 2008 outlier
payments of 1.0 percent of total CY 2008 OPPS payment.
In CY 2008, the OPPS outlier outlay is projected to be 1.0 percent
of total payments. We note that our projections for CY 2008 outlier
payments take into account the final packaging policies, as well as all
other final payment policies, of the OPPS. We acknowledge that outlier
payments are an integral component of the OPPS and could be
particularly important as the APC payment bundles grow larger and
hospitals potentially experience financially greater risk associated
with individual patient encounters. In a movement toward encounter-
based or episode-based payment, multiple service payments for a claim
could become less common, and OPPS outlier payments could come to be
increasingly targeted toward clinical cases rather than individual
services, consistent with the customary role of outlier payment in a
prospective payment system. We prospectively set the outlier thresholds
so that we will pay 1.0 percent of projected payment based on our best
inflation assumptions and model of final payment policies. The final
policy to increase packaging for the CY 2008 OPPS should not result in
less aggregate outlier payment in CY 2008 than other years, although
the distribution of payment across APCs will change.
We believe that the estimated total CY 2008 outlier payments will
meet the target of 1.0 percent of total OPPS payments. In CY 2006,
aggregated outlier payments were 1.1 percent of aggregated total
spending, while the target was set at 1.0. As we indicated in the CY
2007 OPPS/ASC final rule with comment period (71 FR 68010), in the
final set of CY 2005 OPPS claims, aggregated outlier payments were 2.39
percent of aggregated total OPPS payments, while the target was set at
2.0 percent. Similarly, using the final set of CY 2004 OPPS claims,
aggregated outlier payments were 2.5 percent of total OPPS payments,
while the target was set at 2 percent. Hence, our historic estimation
of outlier payments has resulted in outlier payments that exceeded our
target. As noted above, we currently estimate that we will pay 0.7
percent of total payments in outlier payments in CY 2007. We believe
that our proposed methodology that applies charge and CCR inflation
factors to updated CY 2006 claims and overall CCRs from the most recent
OPSF file to approximate CY 2008 values yields an outlier threshold
that will result in more accurate aggregate program outlier payments.
We did not increase the CY 2008 outlier threshold by the market
basket update of 3.3 percent because our calculations are intended to
best approximate the outlier target of 1.0 percent of CY 2008 OPPS
expenditures. We continue to believe that an outlier target of 1.0
percent of total OPPS payment is appropriate for the OPPS. However, we
will monitor outlier payments distributed during CY 2008 to determine
whether a different outlier target would be more appropriate.
Similarly, we do not believe it is appropriate to increase the
payment percentage to 80 percent of the difference between the APC
payment and the cost of the service in order to align it with the IPPS
outlier policy. In a budget neutral system with a specified payment
target, the payment percentage
[[Page 66686]]
and fixed-dollar threshold have an inverse relationship. Raising the
payment percentage would require us to significantly increase the fixed
dollar threshold to ensure that the outlier target is not exceeded. We
agree with most commenters that a relatively lower fixed-dollar
threshold is more desirable for the OPPS than a higher fixed-dollar
threshold, given the current size of the OPPS payment bundles.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, for the outlier
calculation as outlined below.
3. Final Outlier Calculation
For CY 2008, we are applying the overall CCRs from the July 2007
OPSF file with a CCR adjustment factor of 1.0027 to approximate CY 2008
CCRs to charges on the final CY 2006 claims that were adjusted to
approximate CY 2008 charges (using the final charge inflation factor of
1.1278). These are the same CCR adjustment and charge inflation factors
that we used to set the IPPS fixed-dollar threshold for FY 2008 (72 FR
47418). We simulated aggregated CY 2008 outlier payments using these
costs for several different fixed-dollar thresholds, holding the 1.75
multiple constant and assuming that outlier payment would continue to
be made at 50 percent of the amount by which the cost of furnishing the
service would exceed 1.75 times the APC payment amount, until the total
outlier payments equaled 1.0 percent of aggregated estimated total CY
2008 OPPS payments. We estimate that a fixed-dollar threshold of
$1,575, combined with the multiple threshold of 1.75 times the APC
payment rate, will allocate 1.0 percent of aggregated total OPPS
payments to outlier payments.
In summary, for CY 2008 we will continue to make an outlier payment
that equals 50 percent of the amount by which the cost of furnishing
the service exceeds 1.75 times the APC payment amount when both the
1.75 multiple threshold and the fixed-dollar $1,575 threshold are met.
As discussed in section VII.B. of this final rule with comment period,
brachytherapy sources will be eligible for outlier payment beginning in
CY 2008. In addition, the costs of diagnostic radiopharmaceuticals and
contrast media for which CY 2008 payment is packaged into the APC
payments for nuclear medicine and other imaging procedures under the
final packaging approach will contribute to a claim's eligibility for
outlier payment in CY 2008. For CMHCs, if a CMHC provider's cost for
partial hospitalization exceeds 3.4 times the payment rate for APC
0033, the outlier payment is calculated as 50 percent of the amount by
which the cost exceeds 3.4 times the APC payment rate.
H. Calculation of an Adjusted Medicare Payment From the National
Unadjusted Medicare Payment
(We note that the title of this section has been changed from that
used in the CY 2008 OPPS/ASC proposed rule. In that rule this section
was entitled, ``Proposed Calculation of the National Unadjusted
Medicare Payment.'')
The basic methodology for determining prospective payment rates for
HOPD services under the OPPS is set forth in existing regulations at
Sec. 419.31 and Sec. 419.32, and Sec. 419.43 and Sec. 419.44. 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 separate 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 2008 scaled weight for the APC
by the final CY 2008 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 any of the status indicator assignments ``S,'' ``T,'' ``V,''
or ``X,'' as defined in Addendum D1 of this final rule with comment
period, in a circumstance in which the multiple procedure discount does
not apply and the procedure is not bilateral or discontinued, 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. (We refer readers
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.) We confirmed that this labor-related share for hospital
outpatient services is still appropriate during our regression analysis
for the payment adjustment for rural hospitals in the CY 2006 OPPS
final rule with comment period (70 FR 68553).
Individual providers interested in calculating the final payment
amount that they will receive for a specific service from the national
payment rates presented in Addenda A and B to this final rule with
comment period should follow the formulas presented in the following
steps. The formula below is a mathematical representation of step 1
discussed above and identifies the labor-related portion of a specific
payment rate for the specific service.
x--Labor-related portion of the national unadjusted payment rate
x = .60 * (national unadjusted payment rate)
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 2008 under the
IPPS, reclassifications through the MCGRB, section 1886(d)(8)(B)
``Lugar'' hospitals, and section 401 of Pub. L. 108-173. We note that
the reclassifications of hospitals under the one-time appeals process
under section 508 of Pub. L. 108-173 expired on September 30, 2007, and
is no longer applicable in this determination of appropriate wage
values for the CY 2008 OPPS. 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 2008 IPPS
payment rates published in the Federal Register on August 22, 2007 (72
FR 47309 through 47315) and corrected in the correction notice to the
FY 2008 IPPS final rule with comment period published in the Federal
Register on October 10, 2007 (72 FR 57634 through 57738).
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 to this final rule with comment period contains the
qualifying counties and the final wage index increase developed for the
FY 2008 IPPS published in the FY 2008 IPPS final rule with comment
period (72 FR 47339) and corrected in the correction notice to the FY
2008 IPPS final rule with comment period published in the Federal
Register on October 10, 2007 (72 FR 57634 through 57738). This step is
to be followed only
[[Page 66687]]
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.
The formula below is a mathematical representation of step 4
discussed above and adjusts the labor-related portion of the national
payment rate for the specific service by the wage index.
xa--Labor-related portion of the national unadjusted
payment rate (wage adjusted
xa = 60 * (national unadjusted payment rate) * applicable
wage index.
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.The formula below is a mathematical
representation of step 5 discussed above and calculates the remaining
portion of the national payment rate, the amount not attributable to
labor, and the adjusted payment for the specific service.
y--Nonlabor-related portion of the national unadjusted payment rate
y = .40 * (national unadjusted payment rate)
Adjusted Medicare Payment = y + xa
Step 6. If a provider is a SCH, as defined in Sec. 412.92, or an
EACH, which is considered to be a SCH under section
1886(d)(5)(D)(iii)(III) of the Act, and located in a rural area, as
defined in Sec. 412.64(b), or is treated as being located in a rural
area under Sec. 412.103, multiply the wage index adjusted payment rate
by 1.071 to calculate the total payment.
The formula below is a mathematical representation of step 6
discussed above and applies the rural adjustment for rural SCHs.
Adjusted Medicare Payment (SCH or EACH) = Adjusted Medicare Payment
* 1.071
We did not receive any public comments on our proposed methodology
for calculating an adjusted payment from the national unadjusted
Medicare payment amount for CY 2008. Therefore, we are finalizing our
methodology as proposed for CY 2008, without modification.
I. Beneficiary Copayments
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
a specified percentage. For all services paid under the OPPS in CY
2008, 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 copayment amount cannot be less than 20 percent of
the OPD fee schedule amount. Sections 1834(d)(2)(C)(ii) and
(d)(3)(C)(ii) of the Act further require that the copayment for
screening flexible sigmoidoscopies and screening colonoscopies be equal
to 25 percent of the payment amount. We have applied the 25-percent
copayment to screening flexible sigmoidoscopies and screening
colonoscopies since the beginning of the OPPS.
2. Copayment
For CY 2008, we proposed to determine copayment amounts for new and
revised APCs using the same methodology that we implemented for CY
2004. (We refer readers to the November 7, 2003 OPPS final rule with
comment period (68 FR 63458).) The unadjusted copayment amounts for
services payable under the OPPS that will be effective January 1, 2008,
are shown in Addendum A and Addendum B to this final rule with comment
period.
We have historically used standard rounding principles to establish
a 20 percent copayment for those few circumstances where the copayment
rate was between 19.5 and 20 percent using our established copayment
rules. For example, the CY 2008 proposed payment and copayment amounts
for APC 9228 (Tigecycline injection) were $0.91 and $0.18,
respectively. Twenty percent of $0.91 is $0.182. Because it would be
impossible to set a copayment rate at exactly 20 percent in this case,
that is, $0.182, we proposed to round the amount, using standard
rounding principles, to $0.18. Also using standard rounding principles,
19.78 percent ($0.18 as a percentage of $0.91) rounds to 20 percent and
meets the statutory requirement of a copayment amount of at least 20
percent. For CY 2008, APC 9046 (Iron Sucrose Injection) had a proposed
payment amount and copayment amount of $0.37 and $0.08, respectively.
Using our established copayment rules, 20 percent of $0.37 is $0.074.
Normally, we would apply standard rounding principles to achieve an
amount that is payable, here $0.07 rather than $0.074. However, if we
were to set a copayment amount of $0.07, which is 18.9 percent of
$0.37, we would not be setting a copayment rate that is at least 20
percent of the OPPS payment rate. As proposed, we continue to believe
that section 1833(t)(3)(B) of the Act requires us to set a copayment
amount that is at least 20 percent of the OPPS payment amount, not less
than 20 percent. Therefore, we proposed to set the copayment rate for
APC 9046 at $0.08. Eight cents represents the lowest amount that we
could set that would bring the copayment rate to 20 percent or, in this
case, just above 20 percent. We proposed to apply this same methodology
in the future to instances where the application of our standard
copayment methodology would result in a copayment amount that is under
20 percent and cannot be rounded, under standard rounding principles,
to 20 percent.
We did not receive any public comments on this proposal, and,
therefore, we are adopting it as final, without modification.
3. Calculation of an Adjusted Copayment Amount for an APC Group
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 $30.61.
Individuals interested in calculating the their final copayment
liability for a given service from the national copayment rates
presented in Addenda A and B should follow the formulas presented in
the following steps. The formula below is a mathematical representation
of step 1 discussed above and calculates national copayment as a
percentage of national payment for a given service.
b--Beneficiary payment percentage
b = national unadjusted copayment for APC / national unadjusted
payment rate for APC
Step 2. Calculate the wage adjusted payment rate for the APC, for
the provider in question, as indicated in section II.H. of this final
rule with comment period. Calculate the rural adjustment for eligible
providers as indicated in section II.H. of this final rule with comment
period.
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.
[[Page 66688]]
The formula below is a mathematical representation of step 3
discussed above and applies the beneficiary percentage to the adjusted
payment rate for a service calculated under II.H. above, with and
without the rural adjustment, to calculate the final adjusted
beneficiary copayment for a given service.
Wage-adjusted copayment amount for the APC = Adjusted Medicare
Payment * b
Wage-adjusted copayment amount for the APC (SCH or EACH) = (Adjusted
Medicare Payment * 1.071)* b
The unadjusted copayments for services payable under the OPPS that
will be effective January 1, 2008, are shown in Addenda A and B to this
final rule with comment period.
We did not receive any public comments concerning the proposed
methodology for calculating the unadjusted copayment amount for CY
2008. Therefore, we are finalizing our proposal without modification.
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 April and July
Quarterly OPPS Updates for CY 2007
a. Background
For the July quarter of CY 2007, we created a total of 16 new Level
II HCPCS codes, specifically C2638, C2639, C2640, C2641, C2642, C2643,
C2698, C2699, C9728, Q4087, Q4088, Q4089, Q4090, Q4091, Q4092, and
Q4095 that were not addressed in the CY 2007 OPPS/ASC final rule with
comment period that updated the CY 2007 OPPS. We designated the payment
status of these codes and added them through the July 2007 update
(Change Request 5623, Transmittal 1259, dated June 1, 2007). There were
no new Level II HCPCS codes for the April 2007 update. In the CY 2008
OPPS/ASC proposed rule, we also solicited public comment on the status
indicators, APC assignments, and payment rates of these codes, which
were listed in Table 26A and Table 26B of that proposed rule, and now
appear in Tables 10 and 11, respectively, of this final rule with
comment period. Because of the timing of the proposed rule, the codes
implemented through the July 2007 OPPS update were not included in
Addendum B to that rule. In the CY 2008 OPPS/ASC proposed rule, we
proposed to assign the new HCPCS codes for CY 2008 to APCs with the
proposed rates as displayed in Tables 26A and 26B and incorporate them
into Addendum B of this final rule with comment period for CY 2008,
which is consistent with our annual APC updating policy. As noted in
Table 13 of this final rule with comment period, HCPCS codes Q4087,
Q4088, Q4089, Q4090, Q4091, Q4092, and Q4095 will be deleted on
December 31, 2007 and replaced with HCPCS J-codes effective January 1,
2008. Readers should refer to Table 13 for their replacement codes.
b. Implantation of Interstitial Devices (APC 0156)
Effective January 1, 2007, CPT code 55876 (Placement of
interstitial device(s) for radiation therapy guidance (e.g., fiducial
markers, dosimeter), prostate (via needle, any approach), single or
multiple) was implemented. We assigned this code to APC 0156 (Level III
Urinary and Anal Procedures) for CY 2007 on an interim final basis. We
then created a new Level II HCPCS code for a similar interstitial
device implantation service for non-prostate sites, C9728 (Placement of
interstitial device(s) for radiation therapy/surgery guidance (e.g.,
fiducial markers, dosimeter), other than prostate (any approach),
single or multiple). We implemented HCPCS code C9728 effective July 1,
2007 via Program Transmittal 1259 dated June 1, 2007, as a result of
information we received during our evaluation of an application for
assignment of the implantation of a radiation dose verification system
to a New Technology APC. We assigned HCPCS code C9728 to APC 0156
because we believed it was similar to CPT code 55876 from both clinical
and resource perspectives. We proposed to maintain both CPT code 55876
and HCPCS code C9728 in APC 0156 for CY 2008, with a proposed payment
rate of approximately $195.
We received a number of comments on the APC assignments of these
codes, both on the CY 2007 OPPS/ASC final rule with comment period and
on the CY 2008 proposed rule. A summary of the comments and our
response follow.
Comment: A few commenters expressed concern about CMS' interim
final placement of CPT code 55876 in APC 0156 for CY 2007 as shown in
Addendum B to the CY 2007 final rule with comment period. Several
commenters expressed similar concern regarding the proposed CY 2008 APC
assignment for this code. The commenters recommended that the payment
rate for implanting the interstitial devices not incorporate the cost
of the devices, because such items have a range of costs. Several
commenters claimed that the costs of these devices range widely, from
approximately $200 for gold markers, to $900 for implantable
dosimeters, to $1200 for electromagnetic transponders, which they
believed justified separate payment for the various types of
interstitial devices.
Some commenters also expressed concern about the proposed CY 2008
APC placement of a new code that CMS created for non-prostate
applications, specifically HCPCS code C9728 which was assigned to APC
0156, effective July 1, 2007, because it is similar to CPT code 55876.
Several commenters asserted that the payment for HCPCS code C9728
should include the costs of dosimeter sensors, which they believed are
currently excluded. These commenters also noted that payment for CPT
code 55876 excludes the cost of dosimeter sensors. They recommended
that CMS develop Level II HCPCS codes that permit hospitals to report
the specific technologies associated with HCPCS code C9728 and CPT code
55876 in each clinical case and receive appropriate payment for the
specific interstitial device implanted.
Several commenters pointed out that the CPT coding instructions for
CPT code 55876 instruct coders to report the supply of devices for the
implantation procedure separately from CPT code 55876. These commenters
claimed that when the CPT Editorial Panel established the code, it did
not include the implantable interstitial device and the imaging
guidance for the implantation procedure in the code, and, therefore,
both device costs and imaging guidance costs were excluded from the
proposed CY 2008 APC payment for CPT code 55876. Because a dosimeter
sensor could be implanted with CPT code 55876 for prostate
applications, the commenters asserted that its costs are not reflected
in that service. The commenters claimed that, unlike the instructions
for CPT code 55876, the descriptor for HCPCS code C9728 does not direct
coders to report the device separately. These commenters recommended
that CMS assign the DVS[reg] Dosimeter device for any body site to New
Technology APC 1514 (New Technology--Level XIV ($1200-$1300)), with a
payment rate of $1250 for the device for CY 2008. Alternatively, they
suggested that CMS package payment for all of the items and services
needed to implant the dosimeter into payment for a single code which
they recommended be assigned to New Technology APC 1522 (New
Technology--Level XXII ($2000-$2500)). One commenter further claimed
that CMS was required to set the APC assignment for the DVS[reg] device
based on the cost estimate
[[Page 66689]]
included in its New Technology APC application.
Response: Many procedures paid under the OPPS include payment for
various implantable devices, where the procedure cost in an individual
case would vary by the type of device. Our long-standing policy is to
package the costs of implantable devices into payment for the
procedures in which they are used, unless those devices are paid
separately for a limited period of 2 to 3 years based on their
transitional pass-through status. Payment for OPPS services includes
payment for all costs that are directly related and integral to
performing a procedure or furnishing a service on an outpatient basis,
as set forth in Sec. 419.2.
According to our usual practice, when we originally evaluated CPT
code 55876 for APC assignment for CY 2007, we took into consideration
all information available to us about the particular service, as well
as other OPPS services for which we have claims-based cost data. In
particular, we considered the probable utilization of the various
devices, including fiducial markers and dosimeters, whose implantation
could be reported with the CPT code, as well as possible implantation
approaches, recognizing that a prospective payment system is based on
principles of averaging. For established services paid under the OPPS,
payment is generally based on the median cost of the service from
claims data. Although CPT instructions state that the supply of the
implantable device is to be reported separately, we considered the
device costs associated with CPT code 55876, which would be packaged
into payment for the implantation procedure under the OPPS even if the
device were separately reported, when we assigned the CPT code to APC
0156. A previous pass-through device category, C1879 (Tissue marker
(implantable)) for a device that we believe could be reported with CPT
code 55876, was active from August 2000 through December 2002. After
its expiration, the cost of tissue markers has been packaged into the
OPPS payment for the procedures in which they are used. We note that
the line-item CY 2006 median cost for HCPCS code C1879 for an
implantable tissue marker was $88 based on approximately 18,600 units
of this device. Although there was no specific HCPCS device code for a
dosimeter in CY 2007, we would consider payment for the dosimeter
packaged under the OPPS into the implantation procedure and would have
no need to establish a specific HCPCS code for the dosimeter for OPPS
payment purposes. There may be other devices whose implantation would
also be reported with CPT code 55876 and, similarly, we would package
their payment under the OPPS. We note that the CMS HCPCS Workgroup has
created two related supply codes for CY 2008, specifically A4648
(Tissue marker, implantable, any type, each) and A4650 (Implantable
radiation dosimeter, each), which will be packaged under the OPPS for
CY 2008 and which could also be reported in association with CPT code
55876. Therefore, any of these HCPCS codes for devices or supplies,
A4648, A4650 or C1879, are reportable with service codes 55876 or
C9728.
In response to public comments on the CY 2007 OPPS/ASC final rule
with comment period and on the CY 2008 proposed rule on the proposed
assignment of CPT code 55876 for CY 2008, we once again examined
information available to us regarding procedures that could be reported
with the CPT code, along with updated claims data for other OPPS
services. We continue to believe that APC 0156 is the most appropriate
APC assignment for CPT code 55876, based on the expected median cost
and utilization of all of the services that would be reported with the
code under the OPPS. We will first have claims data for CPT code 55876
for the CY 2009 OPPS update, which we will review in the context of our
CY 2009 update proposals.
We note that during CY 2007, we evaluated a New Technology APC
application submitted by the manufacturer of the DVS[reg] System for a
service the applicant entitled ``Implantation of the DVS[reg]
Dosimeter.'' We did not approve an item or service for payment
specifically for the DVS[reg] Dosimeter. However, we approved creation
of a new code for a service for non-prostate placement of interstitial
device(s) for radiation therapy or surgical guidance, using such
devices as fiducial markers or dosimeters. As explained by the
commenters, and similar to CPT code 55876, this procedure could implant
devices with a wide range of costs, including dosimeters that
commenters claimed ranged from $900 to $1200. Our general policy in
creating a new service code under the OPPS, whether we assign it to a
clinical or New Technology APC, is to develop a general service code so
that it may be reported for a range of technologies, rather than only
for a single proprietary service. This reduces potential barriers to
payment under the OPPS for related new services and is consistent with
the general coding practices of the CPT Editorial Panel and the CMS
HCPCS Workgroup. When we approve a new service for assignment to a New
Technology APC, we are not required to set the payment rate based on
the cost data presented in the New Technology APC application alone, as
we have stated in our final rule published in the Federal Register on
November 30, 2001. In that rule, we specifically explained that we do
not limit our determination of the cost of a service to information
submitted by the applicant. We obtain information on costs from other
appropriate sources before making a determination of the cost of the
procedure to hospitals (66 FR 59900). In addition, we note that only
complete services are currently assigned to New Technology APCs, not
items, such as drugs or devices.
In response to comments to the CY 2008 proposed rule on the
proposed assignment of HCPCS code C9728, we examined all information
available to us on procedures that could be reported with the code, as
well as updated cost data from claims regarding other OPPS services. We
continue to believe that the resources and utilization associated with
HCPCS code C9728, including the cost of the various possible
implantable devices that may be implanted in the service and the
different approaches to the implantation, resemble those associated
with CPT code 55876. Therefore, we will maintain HCPCS code C9728 in
APC 0156 for CY 2008. We will first have data for HCPCS code C9728 for
the CY 2009 OPPS update, which we will review in the context of our CY
2009 update proposals. We expect that these data will reflect the costs
of the implantable devices utilized and, the extent that more costly
devices, such as implantable dosimeters and electromagnetic
transponders, are increasingly reported with this procedure, the cost
of these devices will gradually be reflected in the median cost of
HCPCS code C9728.
c. Other New HCPCS Codes Implemented in April or July 2007
While we received public comments on the proposed CY 2008 OPPS
treatment of HCPCS code C9728 as discussed above and HCPCS codes C2638,
C2639, C2640, C2641, C2642, C2643, C2698, and C2699 as discussed in
section VII. of this final rule with comment period, we did not receive
any public comments on the proposed APC assignments and status
indicators for HCPCS codes Q4087, Q4088, Q4089, Q4090, Q4091, Q4092,
and Q4095 that were implemented in July 2007. However, for CY 2008, the
CMS HCPCS Workgroup decided to delete the drug codes described by Q-
codes on December 31, 2007 and replace them with permanent J-codes
effective
[[Page 66690]]
January 1, 2008. Consistent with our general policy of using permanent
HCPCS codes for the reporting of drugs under the OPPS in order to
streamline coding, we are displaying the J-codes in Table 13 that will
replace the seven Q-codes, effective January 1, 2008. We note that Q
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. The J-
codes describe the same drugs and the same dosages as the Q-codes that
will be deleted December 31, 2007. Because we did not receive any
public comments on the proposed CY 2008 APC and status indicator
assignments for the new HCPCS codes, with the exception of HCPCS code
C9728, that were implemented in July 2007, we are adopting our proposal
as final, without modification, and are assigning the replacement HCPCS
J codes to the same status indicators and APCs that were proposed for
the predecessor Q-codes, as shown in Addendum B to this final rule with
comment period.
Table 12.--New Non-Drug Hcpcs Codes Implemented in July 2007
----------------------------------------------------------------------------------------------------------------
Final CY
HCPCS code Long descriptor Final CY 2008 status Final CY 2008 median
indicator 2008 APC cost
----------------------------------------------------------------------------------------------------------------
C2638.................... Brachytherapy source, stranded, K........................ 2638 $45
iodine-125, per source.
C2639.................... Brachytherapy source, non- K........................ 2639 32
stranded, iodine-125, per
source.
C2640.................... Brachytherapy source, stranded, K........................ 2640 65
palladium-103, per source.
C2641.................... Brachytherapy source, non- K........................ 2641 51
stranded, palladium-103, per
source.
C2642.................... Brachytherapy source, stranded, K........................ 2642 97
cesium-131, per source.
C2643.................... Brachytherapy source, non K........................ 2643 63
stranded, cesium-131, per
source.
C2698.................... Brachytherapy source, stranded, K........................ 2698 45
not otherwise specified, per
source.
C2699.................... Brachytherapy source, non- K........................ 2699 31
stranded, not otherwise
specified, per source.
C9728.................... Placement of interstitial T........................ 0156 192
device(s) for radiation therapy/
surgery guidance (eg, fiducial
markers, dosimeter), other than
prostate (any approach) single
or multiple.
----------------------------------------------------------------------------------------------------------------
Table 13.--New Drug Hcpcs Codes Implemented in July 2007
----------------------------------------------------------------------------------------------------------------
Final CY
New HCPCS J-code effective HCPCS Q- Long descriptor 2008 status Final CY
January 1, 2008 code indicator 2008 APC
---------------------------------------------------------------------------------------------------------------
J1568.......................... Q4087 Injection, immune globulin, (Octogam), K 0943
intravenous, non-lyophilized, (e.g.
liquid), 500 mg.
J1569.......................... Q4088 Injection, immune globulin, K 0944
(Gammagard), intravenous, non-
lyophilized, (e.g. liquid), 500 mg.
J2791.......................... Q4089 Injection, rho(d) immune globulin K 0945
(human), (Rhophylac), intravenous,
100 iu.
J1571.......................... Q4090 Injection, hepatitis b immune globulin K 0946
(Hepagam B), intramuscular, 0.5 ml.
J1572.......................... Q4091 Injection, immune globulin, K 0947
(Flebogamma), intravenous, non-
lyophilized, (e.g. liquid), 500 mg.
J1561.......................... Q4092 Injection, immune globulin, (Gamunex), K 0948
intravenous, non-lyophilized, (e.g.
liquid), 500 mg.
J3488.......................... Q4095 Injection, zoledronic acid (Reclast), K 0951
1 mg.
----------------------------------------------------------------------------------------------------------------
2. Treatment of New Category I and III CPT Codes and Level II HCPCS
Codes
a. Establishment and Assignment of New Codes
As has been our practice in the past, we implement new Category I
and III CPT codes and new Level II HCPCS codes through program
transmittals, 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 to the OPPS/ASC
final rule with comment period 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.
(We refer readers to the discussion immediately below concerning our
policy for implementing new Category I and III mid-year CPT codes.) In
the CY 2008 OPPS/ASC proposed rule, we proposed to continue this
recognition and process for CY 2008. Therefore, new Category I and III
CPT codes and new Level II HCPCS codes, effective January 1, 2008, are
listed in Addendum B to 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'' is open to public comment in this final rule with
comment period. As indicated in the CY 2008 OPPS/ASC proposed rule, we
will respond to all comments received concerning these codes in a
subsequent final rule for the next calendar year's OPPS/ASC update.
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 with
comment period to the new codes that are open to public comment.
Therefore, we are finalizing our proposed treatment of new CY 2008
Category I and III CPT codes, as well as the Level II HCPCS codes,
without modification.
We received some comments to the CY 2008 proposed rule regarding
individual new HCPCS codes that commenters expected to be implemented
for the first time in the CY 2008 OPPS. We could not discuss the CY
2008 codes, including their APC
[[Page 66691]]
and/or status indicator assignments, 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 2008 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, 2007, for implementation January 1,
2008, 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.
Effective for January 1, 2008, we have created eight HCPCS C-codes
that describe transthoracic echocardiography with contrast and
transesophageal echocardiography with contrast to enable facilities to
appropriately report contrast-enhanced echocardiography services. (See
section II.A.4.c(6) of this final rule with comment period for further
discussion of these codes). Effective January 1, 2008, these C-codes
will be used by HOPDs to report contrast echocardiography services.
These codes are assigned comment indicator ``NI'' in Addendum B to this
final rule with comment period.
In the CY 2008 OPPS/ASC proposed rule, we also proposed to continue
our policy of the last 2 years of recognizing new mid-year CPT codes,
generally Category III CPT codes, that the AMA releases in January for
implementation the following July through the OPPS quarterly update
process. Therefore, for CY 2008, we proposed to include in Addendum B
to the CY 2008 OPPS/ASC final rule with comment period the new Category
III CPT codes released in January 2007 for implementation on July 1,
2007 (through the OPPS quarterly update process), and the new Category
III codes released in July 2007 for implementation on January 1, 2008.
However, as proposed, only those new Category III CPT codes implemented
effective January 1, 2008, are flagged with comment indicator ``NI'' in
Addendum B to this final rule with comment period, to indicate that we
have assigned them an interim payment status which is subject to public
comment. Category III CPT codes implemented in July 2007, which
appeared in Table 27 of the proposed rule and are displayed in Table 14
of this final rule with comment period, were subject to comment in the
proposed rule, and we proposed to finalize their status in this final
rule with comment period.
b. Electronic Brachytherapy Services (New Technology APC 1519)
The AMA's CPT Editorial Panel created a new Category III code,
0182T (High dose rate (HDR) electronic brachytherapy, per fraction), as
of July 1, 2007. We assigned CPT code 0182T to New Technology APC 1519
(New Technology--Level IXX ($1700-$1800)), with a payment rate of
$1750, as of July 1, 2007 (via Program Transmittal 1259, Change Request
5623).
We received a wide variety of comments regarding the proposed
assignment of CPT code 0182T to New Technology APC 1519. A summary of
the comments and our response follows.
Comment: Some commenters thought the proposed assignment provided a
payment that was too high, some believed the proposed payment was too
low, while others agreed with the proposed APC assignment. A number of
commenters believed that placement of CPT code 0182T into APC 1519
resulted in a payment amount much higher relative to existing APCs for
application of brachytherapy sources, specifically, APCs 0312
(Radioelement Applications), 0313 (Brachytherapy), and 0651 (Complex
Interstitial Radiation Source Application), with proposed CY 2008
payment rates of $534.48, $739.46, and $981.88, respectively. One
commenter indicated that only a very small number of patients would be
treated using electronic brachytherapy. Another commenter expressed
appreciation of CMS's prompt assignment of new technologies to APCs,
while some commenters were concerned that the proposed payment for CPT
code 0182T as a new technology service was between two and three times
the payment rate for the other conventional brachytherapy service APCs
cited above. These commenters believed that the proposed payment for
electronic brachytherapy was excessive and, given that the risks of the
treatment have yet to be clearly established, such conditions would
encourage the early and possibly inappropriate adoption of this
service. Some commenters recommended that CMS consult with specialty
organizations regarding the pricing of new technology services prior to
assigning them to APCs. Other commenters supported the proposed
assignment of CPT code 0182T and recommended that the service reside in
that New Technology APC for at least 2 years.
Another commenter expressed concern that the payment level was too
low for a single fraction treatment of electronic brachytherapy. The
commenter pointed out that two applications for New Technology APCs
were submitted to CMS for electronic brachytherapy with the following
descriptions: (a) HDR electronic brachytherapy, complete course as a
single fraction, and (b) HDR electronic brachytherapy, per fraction.
The commenter claimed that the two forms of HDR electronic
brachytherapy are each unique and should not be classified into the
same APC. The commenter requested that a new HCPCS code for HDR
electronic brachytherapy, complete course as a single fraction, be
developed and assigned to APC 1529 (New Technology--Level XXIX ($5,500-
$6,000)) for CY 2008.
Response: The CY 2008 proposed APC assignment of CPT code 0182T
maintained our initial placement of HDR electronic brachytherapy.
Consistent with our recent OPPS practice for Category III CPT codes
that are implemented mid-year by the AMA, we recognized CPT code 0182T
under the OPPS in July 2007. This recognition ensures timely collection
of data pertinent to the service described by the code, ensures patient
access to the service, and eliminates potential redundancy between
Category III CPT codes and Level II HCPCS codes that are created by us
in response to applications for new technology services.
Commenters did not provide analyses regarding the costs of the
service; however, we received cost estimates from two manufacturers in
their respective New Technology APC applications over the course of an
extensive evaluation period. As is our customary practice, we also used
claims data for related services and other sources of information to
supplement information included in the New Technology APC applications
in order to provide an APC assignment we believed to be appropriate at
this time. Regarding the comments on potential complications or risks
of the new service that has a higher payment rate than conventional
brachytherapy procedures, we note that the APC assignment of a service
based on its estimated cost is our usual practice for new services
under the OPPS, which generally pays for services based on estimated
hospital resources. In the absence of cost data from hospital claims,
we believe that comparisons of OPPS payment for electronic
[[Page 66692]]
brachytherapy to payment for conventional brachytherapy services that
are assigned to APCs 0312, 0313, and 0651 and that implant radioactive
sources are not appropriate. The law specifically requires separate
payment for the brachytherapy sources, and, therefore, these costs are
not included in the procedure payment for conventional brachytherapy
services that are reported for implanting the sources. We define
brachytherapy sources as containing a radioactive isotope so, by
definition, in the case of electronic brachytherapy treatment the New
Technology APC payment for the procedure would include payment for the
costs of the radiation actually delivered to the patient. Thus, it is
not appropriate to compare the costs of conventional and electronic
brachytherapy treatments based on a comparison of the treatment
procedure costs alone.
In light of the commenters' concerns regarding safety of the new
procedures, we reiterate that even though a service is assigned a HCPCS
code and a payment rate under the OPPS, it does not imply coverage by
the Medicare program but indicates only how the service may be paid if
covered by the program. Unless CMS has issued a national coverage
determination (NCD), local contractors determine whether a service
meets all program requirements for coverage. While we do not
specifically consult with specialty organizations during the New
Technology APC application evaluation process that may result in an
initial APC assignment for a service, the APC assignments of new
technology services, like all other OPPS services, are open to comment
in the annual OPPS update, and we welcome public comments.
We will not create a new Level II HCPCS code for HDR electronic
brachytherapy, complete course as a single fraction, and assign it to a
different New Technology APC. We evaluated both New Technology APC
applications at length and received input from both applicants. We
believe that the two forms of HDR electronic brachytherapy, whether
provided in a single fraction or multiple fractions depending on the
technology, are both described by CPT code 0182T that is appropriately
assigned to a single APC. We note that the payment is per fraction, and
that would include a single fraction treatment as well.
After reviewing the public comments received and all current
information available to us regarding HDR electronic brachytherapy and
other hospital outpatient services, we continue to believe that New
Technology APC 1519, with a payment rate of $1750, is the most
appropriate assignment for CPT code 0182T. Therefore, we are finalizing
our proposal, without modification, to maintain the assignment of CPT
code 0182T to New Technology APC 1519, with a payment rate of $1750 for
CY 2008.
c. Other Mid-Year CPT Codes
We did not receive any comments on the proposed CY 2008 APC and
status indicator assignments of Category III CPT codes first
implemented in July 2007 for services other than CPT code 0182T. After
considering the public comments received on CPT code 0182T, we are
finalizing our general proposal for the treatment of new mid-year CPT
codes, including our proposed APC assignments for CPT code 0182T and
other Category III CPT codes as displayed Table 14.
Table 14.--Category III CPT Codes Implemented in July 2007
----------------------------------------------------------------------------------------------------------------
Final CY 2008 status
CPT code Long descriptor indicator Final CY 2008 APC
----------------------------------------------------------------------------------------------------------------
0178T.................. Electrocardiogram, 64 leads or B...................... Not applicable.
greater, with graphic
presentation and analysis;
with interpretation and
report.
0179T.................. Electrocardiogram, 64 leads or X...................... 0100
greater, with graphic
presentation and analysis;
tracing and graphics only,
without interpretation and
report.
0180T.................. Electrocardiogram, 64 leads or B...................... Not applicable.
greater, with graphic
presentation and analysis;
interpretation and report
only.
0181T.................. Corneal hysteresis S...................... 0230
determination, by air impulse
stimulation, bilateral, with
interpretation and report.
0182T.................. High dose rate electronic S...................... 1519
brachytherapy, per fraction.
----------------------------------------------------------------------------------------------------------------
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 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 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 similar 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 payment for each procedure or service within
an APC group the costs associated with those items or services that are
directly related to and supportive of performing the main procedures or
furnishing services. 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 final rule with comment period); and (7) incidental
services such as venipuncture. Our final packaging methodology for
ancillary and supportive services is discussed in section II.A.4.c. of
this final rule with comment period.
Under the OPPS, we pay for hospital outpatient services on a rate-
per-service basis, where the service may be reported with one or more
HCPCS codes. Payment varies according to the APC group to which the
independent service
[[Page 66693]]
or combination of services 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 it is the middle level clinic
visit APC (that is, where the Level 3 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 hospital
outpatient setting.
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 the CY 2008 OPPS and our
responses to them are discussed in the relevant specific sections
throughout this final rule with comment period).
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 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 2007 meeting, we presented median cost
and utilization data for services furnished during the period of
January 1, 2006, through September 30, 2006, 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 2008 are contained
principally in sections III.C. and III.D. of this final rule with
comment period.
In addition to the assignment of specific services to APCs that 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 to the proposed rule. In these cases, to eliminate a 2 times
violation or to improve clinical and resource homogeneity, we proposed
to reassign the codes to APCs that contained services that were similar
with regard to both their clinical and resource characteristics. We
also proposed to rename existing APCs, discontinue existing APCs, or
create new clinical APCs to complement proposed HCPCS code
reassignments. In many cases, the proposed HCPCS code reassignments and
associated APC reconfigurations for CY 2008 included in the proposed
rule were related to changes in median costs of services and APCs
resulting from our proposed bundling approach for CY 2008, as discussed
in section II.A.4.c. of the proposed rule. 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 proposed
to change 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 the policies that we proposed for CY
2008.
Addendum B to the 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 2007 Addendum B
update (via Change Request 5544, Transmittal 1209, dated March 21,
2007). Addendum B to this final rule with comment period identifies
with the ``CH'' comment indicator the final CY 2008 changes compared to
the codes' status as reflected in the October 2007 Addendum B update
(via Change Request 5718, Transmittal 1336, dated September 14, 2007).
We received many public comments regarding the proposed APC and
status indicator assignments for CY 2008 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 2008 related to
each HCPCS code is noted in those sections. We also received a number
of specific comments about some of the procedures assigned to APCs that
may have violated the 2 times rule. These comments are addressed
elsewhere in the final rule with comment period, primarily in sections
related to the types of procedures that were the subject of the
comments.
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. Taking into account the APC changes
that we proposed for CY 2008 based on the APC Panel recommendations
discussed mainly in sections III.C. and III.D. of this final rule with
comment period, the proposed changes to status indicators and APC
assignments as identified in Addendum B to the proposed rule, and the
use of CY 2006 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, we refer readers to
the April 7, 2000 OPPS final rule with comment period (65 FR 18457).
Table 28 of the proposed rule listed the APCs that we proposed to
exempt from the 2 times rule for CY 2008 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 2008. The
median costs for hospital outpatient services for these and all other
APCs that were used in the development of the proposed rule can
[[Page 66694]]
be found on the CMS Web site at: 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, specifically those listed
in Table 28 of the proposed rule. For the proposed rule, the list of
APCs excepted from the 2 times rule were based on data from January 1,
2006, through September 30, 2006. For this final rule with comment
period, we used data from January 1, 2006 through December 1, 2006.
Thus, after responding to all of the comments on the proposed rule and
making changes to APC assignments based on the comments received, we
analyzed the full CY 2006 data to identify APCs with 2 times rule
violations. In contrast to previous years, for CY 2008 we have
calculated a significant number of APC medians through customized
methodologies, such as device-dependent APC, APCs to which nuclear
medicine procedures are assigned, and Visit APCs, that are impacted by
the Extended Assessment and Management Composite APCs. Therefore, for
this final rule with comment period we assessed the HCPCS code-specific
median costs for HCPCS codes that are part of these customized APC
median cost calculations to accurately identify 2 times violations. We
also have some APCs where the concept of a 2 times violation is not
relevant, typically those set based on multiple claims, such as APC
0381 for single allergy tests and APC 0375 for ancillary services when
a hospital outpatient dies. Table 15 below has been revised relative to
prior years to remove APCs where a 2 times violation is not a relevant
concept and to identify final APCs, including those with customized
median cost methodologies, with 2 times violations.
Based on our final data, we found that there were 21 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 2008.
After consideration of all public comments received on the proposed
rule and the careful review of the CY 2006 claims data for the full
year, we are finalizing the list of APCs exempted from the 2 times
rule. The final list of APCs that are exceptions to the 2 times rule
for CY 2008 is displayed in Table 15 below.
Table 15.--Final APC Exceptions to the 2 Times Rule for CY 2008
------------------------------------------------------------------------
APC APC title
------------------------------------------------------------------------
0043............................ Closed Treatment Fracture Finger/Toe/
Trunk.
0058............................ Level I Strapping and Cast
Application.
0060............................ Manipulation Therapy.
0080............................ Diagnostic Cardiac Catheterization.
0093............................ Vascular Reconstruction/Fistula Repair
Without Device.
0105............................ Repair/Revision/Removal of Pacemakers,
AICDs, or Vascular Devices.
0106............................ Insertion/Replacement of Pacemaker
Leads and/or Electrodes.
0141............................ Level I Upper GI Procedures.
0235............................ Level I Posterior Segment Eye
Procedures.
0251............................ Level I ENT Procedures.
0256............................ Level V ENT Procedures.
0260............................ Level I Plain Film Except Teeth.
0303............................ Treatment Device Construction.
0323............................ Extended Individual Psychotherapy.
0330............................ Dental Procedures.
0409............................ Red Blood Cell Tests.
0432............................ Health and Behavior Services.
0437............................ Level II Drug Administration.
0438............................ Level III Drug Administration.
0604............................ Level 1 Hospital Clinic Visits.
0688............................ Revision/Removal of Neurostimulator
Pulse Generator Receiver.
------------------------------------------------------------------------
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.
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 increments of $100, and from $2,000 through
$10,000 in increments of $500. These increments, 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.
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 cost bands, reassign the procedure or
service to a different New Technology APC that most appropriately
reflects its cost.
At its March 2007 meeting, the APC Panel recommended that CMS keep
services in New Technology APCs until sufficient data are available to
assign them to clinical APCs, but for no longer than 2 years. We note
that because of the potential for quarterly assignment of new services
to New Technology APCs and the 2-year time lag in claims data for an
OPPS update (that is, CY 2006 data are utilized for this CY 2008 OPPS
rulemaking cycle), if we were to accept the APC Panel's recommendation,
we would always reassign services from New Technology to clinical APCs
based on 1 year or less of claims data. For example, if a new service
was first assigned to a New Technology APC in July 2006, we would have
6 months of data for purposes of CY 2008 rulemaking but, in order to
ensure that the service was in a New Technology APC for no longer than
2 years, we would need to move the service to a clinical APC for CY
2008. While we might have sufficient claims data from 6 months of CY
2006 to support a proposal for such a reassignment for CY 2008, we are
not confident that this would always be the case for all new services,
given our understanding of the dissemination of new technology
procedures into medical practice and the diverse characteristics of new
technology services that treat different clinical conditions.
Therefore, we did not accept the APC Panel's recommendation for CY 2008
because we believed that accepting the recommendation would limit our
ability to individually assess the OPPS treatment of each new
technology service in the context of available hospital claims data. We
are particularly concerned about continuing to provide appropriate
payment for low volume new technology services that may be
[[Page 66695]]
expected to continue to be low volume under the OPPS due to the
prevalence of the target conditions in the Medicare population. We
appreciate the APC Panel's thoughtful discussion of new technology
services, and we agree with the APC Panel that it should be our
priority to regularly reassign services from New Technology APCs to
clinical APCs under the OPPS, so that they are treated like most other
OPPS services for purposes of ratesetting once hospitals have had
sufficient experience with providing and reporting the new services.
Rather, consistent with our current policy, for CY 2008 we proposed to
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. The flexibility associated with 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 2 years if sufficient
hospital claims data upon which to base a decision for reassignment
have not been collected.
We received a number of public comments on our OPPS treatment of
New Technology services. A summary of the public comments and our
responses follow.
Comment: Several commenters requested that CMS reconsider
maintaining a new service in a New Technology APC for a minimum of at
least 2 years, to ensure sufficient claims data, before assigning it to
a clinical APC. These commenters were concerned that reassigning a new
service from a New Technology APC to a clinical APC in less than 2
years may result in the collection of inaccurate claims data because
integration of new technologies can be slow and hospitals need time to
update their chargemasters to appropriately include charges that are
related to the actual costs of the new service. Other commenters
reported that while a new technology service may increase hospital
outpatient costs, it could ultimately replace more invasive inpatient
procedures that are more costly for the Medicare program.
In addition, several commenters recommended that CMS place all new
HCPCS codes for new services in New Technology APCs, rather than
assigning them directly to clinical APCs, until claims data are
available in order to ensure access to these services. Some commenters
also recommended that CMS consider alternatives to moving procedures
from New Technology APCs to clinical APCs that would prevent excessive
reductions in payment, including moving procedures to different APCs,
utilizing external data for ratesetting, or maintaining procedures in
their current New Technology APCs.
Response: As we have stated previously, we generally keep a
procedure in the New Technology APC to which it is initially assigned
until we have collected sufficient claims data 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. This
policy would allow 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, and also allows us to move a
service from a New Technology APC in less than 2 years if sufficient
claims data are available. To retain a new service under a New
Technology APC for a minimum of at least two years, especially for a
service for which we have significant claims data, may result in
inappropriate payment of the service. We want to ensure appropriate
allocation of Medicare expenditures, and for a service that has been
placed in a New Technology APC with significant claims data, we believe
it is in the best interest of both the Medicare program and the
beneficiary to reassign the service to an appropriate clinical APC
based on clinical coherence and resource similarity.
In response to the different suggestions for transitioning new
technology services from New Technology APCs to clinical APCs to
prevent excessive reductions in payment, because we generally move new
services from New Technology APCs to clinical APCs only when we have
adequate data upon which to base a decision, we do not believe a
transition would commonly be necessary in order to provide appropriate
payment for the services based on their hospital costs. We have no need
to utilize external data in these cases where we believe our claims
data, developed according to the standard OPPS ratesetting methodology,
are adequate to reassign the new services to clinical APCs. In a few
past situations, we have moved services from one New Technology APC to
another New Technology APC with a lower payment rate if we believed
that our data were not fully developed to support a final clinical APC
assignment, but we expect these cases to continue to be rare. In
addition, all reassignments of services out of New Technology APCs are
proposed during the annual rulemaking cycle, allowing the opportunity
for public comment prior to their movement.
When evaluating new services for payment under the OPPS, we use all
information available to us regarding the clinical characteristics of
the procedures and the expected hospital resource costs. We reserve New
Technology APC assignments for those services where we do not believe
there is an appropriate clinical APC for the new service. In many
cases, new HCPCS codes describe services that are similar to existing
services that are paid under the OPPS and for which we have robust cost
data from hospital claims. We continue to believe that it is
appropriate to assign similar new and existing services to the same
clinical APC in such cases. We follow the claims data closely and
carefully review the New Technology and clinical APC assignments of
relatively new OPPS services for each update year when new claims data
become available. In addition, the OPPS treatment of all new services
is open to public comment in the annual OPPS/ASC rule (either proposed
or final with comment period) that follows the service's implementation
under the OPPS.
After consideration of all public comments received, we are
finalizing our CY 2008 proposal, without modification, to maintain a
new service in a New Technology APC until we gather sufficient claims
data to assign the service to a clinically appropriate APC. Thus, a
service can be assigned to a New Technology APC for more than 3 years
if we have insufficient claims data to reassign the service to a
clinical APC, or it could be reassigned to a clinical APC in less than
2 years if we have adequate claims data. We will continue to assess new
services for potential assignment to clinical APCs before assigning
them to New Technology APCs.
The procedures presented below in sections III.C.2.a., III.C.2.b.,
and III.C.2.c. represent services assigned to New Technology APCs for
CY 2007 for which we stated in the CY 2008 proposed rule that we
believed we had sufficient data to propose their reassignment to
clinically appropriate APCs for CY 2008.
[[Page 66696]]
a. Positron Emission Tomography (PET)/Computed Tomography (CT) Scans
(APC 0308)
From August 2000 through April 2005, we 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 to the
November 15, 2004 final rule with comment period (69 FR 65682) urged
that we 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 which 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 the CPT codes 78814 (Tumor imaging,
positron emission tomography (PET) with concurrently acquired computed
tomography (CT) for attenuation correction and anatomical localization;
limited area (eg, chest, head/neck)); 78815 (Tumor imaging, positron
emission tomography (PET) with concurrently acquired computed
tomography (CT) for attenuation correction and anatomical localization;
skull base to mid-thigh); and 78816 (Tumor imaging, positron emission
tomography (PET) with concurrently acquired computed tomography (CT)
for attenuation correction and anatomical localization; whole body) 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, while we proposed to reassign both PET and PET/CT
scans to the same new clinical APC, we finalized a policy that
reassigned conventional PET procedures to APC 0308 (Non-Myocardial
Positron Emission Tomography (PET) Imaging) with a final median cost of
approximately $850. We also reassigned PET/CT services to a different
New Technology APC for CY 2007, specifically New Technology APC 1511
(New Technology--Level XI ($900-$1000)), thereby maintaining the
historical payment differential of about $100 between PET and PET/CT
procedures. Furthermore, we stated in the CY 2007 OPPS/ASC final rule
with comment period (71 FR 68022) that we would 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 was warranted for CY 2007.
For CY 2008, we proposed the reassignment of concurrent PET/CT
scans, specifically CPT codes 78814, 78815, and 78816, to a clinical
APC because we believed we had adequate claims data from CY 2006 upon
which to determine the median cost of performing these procedures.
Based on our proposed rule analysis of approximately 117,000 CY 2006
single claims, the median cost of PET/CT scans was approximately
$1,094. We then examined approximately 34,000 single claims from CY
2006 for nonmyocardial PET scans, as described by CPT codes 78608,
78811, 78812, and 78813, and found that the median cost was also
approximately $1,094. In the proposed rule, we noted that a comparison
of the median cost of PET/CT scans with the median cost of
nonmyocardial PET scans, as derived from CY 2006 claims data,
demonstrated that these costs were almost the same, thereby reflecting
significant hospital resource equivalency between the two types of
services. This result was not unexpected because many newer PET
scanners also have the capability of rapidly acquiring CT images for
attenuation correction and anatomical localization, sometimes with
simultaneous image acquisition. The median costs for both PET and PET/
CT scans were significantly higher for CY 2008 than for CY 2007 due to
our CY 2008 proposal to package payment for all diagnostic
radiopharmaceuticals as described in section II.A.4.c.(5) of this final
rule with comment period that would package payment for the costs of
the radiopharmaceuticals utilized similarly into the payment for both
PET and PET/CT scans. As stated in the proposed rule (72 FR 42705), we
believe that our claims data accurately reflected the comparable
hospital resources required to provide nonmyocardial PET and PET/CT
procedures, and that the scans had obvious clinical similarity as well.
Therefore, for CY 2008 we proposed to reassign the CPT codes for PET/CT
scans to the clinical APC where nonmyocardial PET scans were also
assigned, specifically APC 0308, with a proposed median cost of
approximately $1,094.
We noted in the proposed rule (72 FR 42705) that we had been paying
separately for fluorodeoxyglucose (FDG), the radiopharmaceutical
described by HCPCS code A9552 (F18 fdg), that is commonly administered
during nonmyocardial PET and PET/CT procedures. For CY 2008, consistent
with the proposed packaging approach as discussed in section
II.A.4.c.(5) of the proposed rule, we proposed to package payment for
the diagnostic radiopharmaceutical FDG into payment for the associated
PET and PET/CT procedures. Because FDG was the most commonly used
radiopharmaceutical for both PET and PET/CT scans and our single claims
for these procedures included FDG more than 80 percent of the time, the
packaging of this radiopharmaceutical fully maintained the clinical and
resource homogeneity of the reconfigured APC 0308 that we proposed.
We received a number of public comments concerning our proposed
reassignment of concurrent PET/CT scans for CY 2008. A summary of the
public comments and our response follow.
Comment: Several commenters thanked CMS for proposing to increase
the payment rate for concurrent PET/CT scans from the CY 2007 payment
of approximately $950 to approximately $1,107 for CY 2008 and ensuring
that these scans are assigned to a clinical APC with other services
with similar median costs. However, these commenters were concerned
that the proposed payment rate for the PET/CT scans for CY 2008 would
be inadequate if the payment for the diagnostic radiopharmaceutical
used in these procedures, specifically FDG, was packaged into the
payment for the scans. Other commenters questioned the validity of the
claims used to set the proposed payment rate for the concurrent PET/CT
scan procedures. They indicated that the proposal to assign concurrent
PET/CT scans from a New Technology APC to clinical APC 0308 was
inappropriate and unsupported by reliable data. They believed that CMS
did not have sufficient or accurate claims data to justify movement of
the concurrent PET/CT services from New Technology APC 1514 to clinical
APC 0308. Several
[[Page 66697]]
commenters suspected that the claims used to set the proposed payment
rate were flawed because they believed that many hospitals had not yet
updated their chargemasters to distinguish charges for the conventional
nonmyocardial PET scans from charges for concurrent PET/CT scans. One
commenter indicated that if CMS were to blend its own external data
from the refined direct cost inputs used to establish the practice
expense relative value units under the MPFS with OPPS claims data to
establish a payment rate for PET/CT, the payment rate would be
significantly higher than the proposed payment. Several commenters
claimed that that proposed payment rate for the concurrent PET/CT
procedures failed to recognize the differences in technology between
the conventional nonmyocardial PET procedures and the concurrent PET/CT
scans. They indicated that concurrent PET/CT scans used more advanced
technology, resulting in greater capital equipment costs. Many
commenters recommended that CMS continue to assign these PET/CT scans
to a New Technology APC for one more year while CMS collects additional
data on the cost of these procedures. Conversely, several commenters
strongly urged CMS to assign the concurrent PET/CT scans to a separate
clinical APC, distinct from the APC for conventional PET scans, to
better reflect the incremental cost differences associated with this
technology.
Response: As stated above, CPT codes 78814, 78815, and 78816 were
new codes in CY 2005 and were assigned to New Technology APC 1514 with
a payment rate of $1,250. We continued with this same APC assignment in
CY 2006. In CY 2007, we assigned these services to a different New
Technology APC, specifically New Technology APC 1511, with a payment
rate of $950 in order to maintain the historical payment differential
of about $100 between the conventional PET and concurrent PET/CT
procedures. For CY 2007 ratesetting, we had only 9 months of claims
data and public commenters were concerned that these data did not yet
reflect updated and appropriate hospital charges specifically for PET/
CT scans. Therefore, concurrent PET/CT scan procedures have been
assigned to a New Technology APC under the OPPS since CY 2005, a period
of almost 3 years.
As we have stated in other sections of this final rule with comment
period, such as in section III.D., comparisons between the MPFS and
OPPS payments for services are not appropriate because the MPFS applies
a very different methodology for establishing the payment for the
physician's office practice expenses associated with a procedure, based
on direct cost inputs. Consequently, the application of the different
methodologies results in different payment amounts in the two settings.
As noted previously, under the OPPS, we retain services within New
Technology APC groups where they are assigned according to our
estimates of their costs until we gather sufficient claims data to
enable us to assign the services to clinically appropriate APCs based
on hospital resource costs as calculated from claims. We disagree with
the commenters' argument that we have insufficient claims data to
justify movement of concurrent PET/CT scans from New Technology APC
1511 to clinical APC 0308. For this final rule with comment period, our
updated claims data for concurrent PET/CT scans showed a total of over
149,000 services performed, with about 126,000 single claims available
for ratesetting. The median cost for PET/CT scans alone was
approximately $1,076. Similarly, we had over 40,000 total claims for
conventional PET scans, with approximately 35,000 single claims
available for ratesetting. The median cost for conventional PET scans
alone was approximately $1,029, very close to the median cost of PET/CT
scans. Based on their common clinical characteristics and the hospital
resource similarity observed in our claims data for conventional PET
and concurrent PET/CT scans, we believe that our claims data are
sufficiently robust to support reassignment of PET/CT scans to the same
clinical APC as conventional PET scans. The final median cost of APC
0308 of approximately $1,044 appropriately reflects the similar costs
of both conventional PET and concurrent PET/CT scans.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to assign
concurrent PET/CT scan procedures described by CPT codes 78814, 78815,
and 78816 to clinical APC 0308, with a CY 2008 median cost of
approximately $1,044, which includes packaged costs for diagnostic
radiopharmaceuticals used in the scans. For further discussion of our
final CY 2008 payment policy for diagnostic radiopharmaceuticals, refer
to section II.A.4.c.(5) of this final rule with comment period.
b. IVIG Preadministration-Related Services (APC 0430)
In CY 2006, we created the temporary HCPCS code G0332 (Services for
intravenous infusion of immunoglobulin prior to administration (this
service is to be billed in conjunction with administration of
immunoglobulin)). Based on our estimate of the costs of this service in
comparison with other services, HCPCS code G0332 was assigned to New
Technology APC 1502 (New Technology--Level II, $50-$100), with a
payment rate of $75 effective January 1, 2006. In the CY 2007 OPPS/ASC
final rule with comment period, we indicated our belief that it was
appropriate to continue the temporary IVIG preadministration-related
services payment through HCPCS code G0332 and its continued assignment
to New Technology APC 1502 for CY 2007, in order to help ensure
continued patient access to IVIG (71 FR 68092).
For CY 2008, we proposed to continue to provide separate payment
for IVIG preadministration-related services through the assignment of
HCPCS code G0332 to a clinical APC. This service has been assigned to a
New Technology APC under the OPPS for 2-full years. As noted
previously, under the OPPS, we retain services within New Technology
APC groups where they are assigned according to our estimates of their
costs until we gather sufficient claims data to enable us to assign the
services to clinically appropriate APCs based on hospital resource
costs as calculated from claims. According to our analysis of the
hospital outpatient claims data, we noted we had adequate claims data
from CY 2006 upon which to determine the median cost of performing IVIG
preadministration related services and to reassign HCPCS code G0332 to
an appropriate clinical APC for CY 2008. For the CY 2008 OPPS/ASC
proposed rule, our claims data for this high volume service showed a
total of over 49,000 services performed, with about 48,000 single
claims available for ratesetting. Therefore, we proposed to reassign
HCPCS code G0332 to new clinical APC 0430 (Drug Preadministration--
Related Services) for CY 2008, with a proposed median cost of
approximately $39, where it would be the only service assigned to the
APC at this time.
As noted in the proposed rule (72 FR 42705), IVIG
preadministration-related services are always provided in conjunction
with other separately payable services such as drug administration
services, and thus are well suited for packaging into the payment for
the separately payable services. While we did not make a determination
about the appropriateness of continuing separate OPPS payment for HCPCS
code G0332 after CY 2008, we stated in the proposed rule (72 FR
[[Page 66698]]
42705) that we would consider packaging payment for HCPCS code G0332 in
future years if we determined that separate payment was no longer
warranted. We intend to reevaluate the appropriateness of separate
payment for IVIG preadministration-related services for the CY 2009
OPPS rulemaking cycle, especially as we explore the potential for
greater packaging and possible encounter-based or episode-based OPPS
payment approaches.
We received a number of public comments on our CY 2008 proposed
payment for IVIG preadministration-related services. A summary of the
public comments and our response follow.
Comment: Many commenters questioned the accuracy and reliability of
the CY 2006 hospital outpatient claims data that were used to set the
proposed payment rate for HCPCS code G0332. Some commenters indicated
that because HCPCS code G0332 was a new code for CY 2006, it was
clearly not well understood by many hospitals, and as a result, it took
some time for hospitals to appropriately determine the cost and the
reported charge for the service. Many commenters stated that the
proposed payment rate of $39 was likely based on flawed data, and as
such, the data should not be used as a basis for reassigning HCPCS code
G0332 from New Technology APC 1502 to APC 0430. These commenters
believed that the low payment rate was due to underreporting of this
service because their findings revealed that hospitals reported HCPCS
code G0332 on only 49 percent of the claims for IVIG administration.
One commenter believed that, based on an analysis of its hospital
system's claims data for HCPCS code G0332, that claims data were
distorted due to a number of factors, including revenue code selections
by hospitals, differences in the CCRs mapped to those revenue codes,
and the actual dollar charges reported by hospitals for this service.
Several commenters explained that hospitals set widely varying charges
for HCPCS code G0332, and some of these commenters believed that it
would be appropriate to exclude from the ratesetting process claims
where the reported charge is equal to or less than the $75 payment
rate.
Many commenters believed that reducing this add-on payment would
have a negative impact on patient access to care, considering the short
supply and high costs of acquiring IVIG. Several commenters suggested
that CMS should maintain the $75 add-on payment for HCPCS code G0332 to
maintain parity with the proposed $71 MPFS payment rate for this
service. These commenters asserted that establishing a difference in
payment for HCPCS code G0332 across systems could drive patients from
one site of service to another. They further believed that maintaining
payment parity for the service at comparable levels across these sites
of service would mitigate potential disruptions to the sites of service
where patients are now receiving care and would also allow the choice
of site of care to be dictated by particular patient circumstances.
Several commenters commended CMS for continued support in extending the
add-on payment for HCPCS code G0332; however, they recommended that the
$75 separate payment under New Technology APC 1502 be continued for
another year. Alternatively, several commenters requested that CMS
reassign HCPCS code G0332 to a clinical APC whose payment rate is
equivalent to $75 to ensure that hospitals would continue to be paid
appropriately for the full range of costs incurred in furnishing IVIG
to their patients and to help mitigate the possible adverse financial
impact on hospitals acquiring IVIG that could result from a lower
payment for preadministration-related services.
Response: Just as our payment rates are updated annually, so too
are billing codes (that is, ICD-9-CM, Level II HCPCS, and CPT). Annual
updates to the HCPCS coding system (whether through addition of a new
code, revision of a code descriptor, or deletion of a code), are a
well-established and predictable process that has been in place for
some time. Hospitals are well aware of this practice because they have
successfully implemented these changes each year.
The MPFS applies a distinct methodology for establishing the
payment for the physician's office practice expenses associated with a
procedure that differs significantly from the OPPS methodology which
generally pays based on relative payment weights calculated from
hospitals' costs as determined from claims data. The application of the
different methodologies results in different payment amounts in the two
settings. Therefore, comparisons between OPPS and MPFS payments are not
appropriate.
In determining the CY 2008 final rule median cost of approximately
$37 for HCPCS code G0332, we used the most recent claims data available
under the OPPS, specifically CY 2006 claims. According to our standard
OPPS methodology as described in section II.A.2. of this final rule
with comment period, we excluded claims for HCPCS code G0332 where the
line-item charge was exactly equal to the CY 2006 payment rate, a
process we followed for all OPPS services. We did not remove claims
whose charges were less than $75 because hospitals are free to set
their own charges for individual services based on their own judgment.
Under the OPPS, the current payment methodology for IVIG treatments
consists of three components, which include payment for the drug itself
(described by a HCPCS J code), administration of the IVIG product
(described by one or more CPT codes), and the preadministration-related
services (HCPCS code G0332). As stated previously, this service has
been assigned to New Technology APC 1502 under the OPPS for 2 full
years. Under the OPPS, we retain services within New Technology APC
groups where they are assigned according to our estimates of their
costs until we gather sufficient claims data to enable us to assign the
services to clinically appropriate APCs based on hospital resource
costs as calculated from claims. We do not agree with the commenters'
argument that underreporting of this service in CY 2006 is a compelling
rationale for delaying reassignment to a clinical APC. Our CY 2006
claims data include approximately 59,000 total claims for HCPCPS code
G0332, and we have no reason to believe those claims do not accurately
represent the costs to hospitals of providing the service in CY 2006.
We believe that the approximately 57,000 single claims used to set the
CY 2008 median cost of IVIG preadministration-related services at
approximately $37 accurately reflect hospitals' costs for the service
and that the final CY 2008 payment rate for HCPCS code G0332 is
adequate to ensure access to IVIG therapy.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to assign HCPCS
code G0332 to APC 0430, with a median cost of approximately $37. As we
stated previously, we will consider packaging payment for HCPCS code
G0332 in future years if we determine separate payment is no longer
warranted. We intend to reevaluate the appropriateness of separate
payment for IVIG preadministration-related services for the CY 2009
OPPS rulemaking cycle, especially as we explore the potential for
greater packaging and possible encounter-based or episode-based OPPS
payment approaches.
[[Page 66699]]
c. Other Services in New Technology APCs
Other than the concurrent PET/CT and IVIG preadministration-related
new technology services discussed in sections III.C.2.a. and III.C.2.b.
of this final rule with comment period, there are five procedures
currently assigned to New Technology APCs for CY 2007 for which we
believed we also had data that were adequate to support their
reassignment to clinical APCs. For CY 2008, we proposed to reassign
these procedures to clinically appropriate APCs, applying their CY 2006
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 29 of the proposed rule. This table
has been reproduced as Table 16 at the end of this section and updated
with the final status indicators, APC assignments, and median costs of
these services.
(1) Breast Brachytherapy Catheter Implantation (APC 0648)
For CY 2008, we proposed to reassign CPT code 19298 (Placement of
radiotherapy afterloading brachytherapy catheters (multiple tube and
button type) into the breast for interstitial radioelement application
following (at the time of or subsequent to) partial mastectomy,
includes imaging guidance) from New Technology APC 1524 (New
Technology--Level XXIV ($3,000-$3,500)) to APC 0648 (Level IV Breast
Surgery), with a proposed median cost of approximately $3,417.
We received several public comments concerning the proposed
reassignment of CPT code 19298. A summary of the public comments and
our response follow.
Comment: Several commenters agreed with CMS's proposal to reassign
CPT code 19298 to APC 0648. They acknowledged that this proposed
reassignment of CPT code 19298 would place the three surgical codes for
the placement of catheters for breast brachytherapy in the same APC,
that is, CPT codes 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); 19297 (Placement of
radiotherapy afterloading balloon catheter into the breast for
interstitial radioelement application following partial mastectomy,
includes imaging guidance; concurrent with partial mastectomy (List
separately in addition to code for primary procedure)); and 19298.
Response: We thank the commenters for their input and support.
Because of its clinical and resource characteristics similar to those
other procedures also assigned to APC 0648, we are finalizing our CY
2008 proposal, without modification, to reassign CPT code 19298 to APC
0648, with a median cost of approximately $3,560.
(2) Preoperative Services for Lung Volume Reduction Surgery (LVRS)
(APCs 0209 and 0213)
As illustrated in Table 16 below, CY 2008, we proposed to reassign
HCPCS codes G0302 (Pre operative pulmonary surgery services for
preparation for LVRS, complete course of services, to include a minimum
of 16 days of services) and G0303 (Pre-operative pulmonary surgery
services for preparation for LVRS, 10 to 15 days of services) to APC
0209 (Level II Extended EEG and Sleep Studies). For CY 2008, we also
proposed to reassign HCPCS codes G0304 (Pre-operative pulmonary surgery
services for preparation for LVRS, 1 to 9 days of services) and G0305
(Post-discharge pulmonary surgery services after LVRS, minimum of 6
days of services) to APC 0213 (Level I Extended EEG and Sleep Studies).
We did not receive any public comments on these two proposals and,
therefore, we are finalizing our CY 2008 proposals for HCPCS codes
G0302, G0303, G0304, and G0305 without modification. Specifically,
HCPCS codes G0302 and G0303 are assigned to APC 0209, with a CY 2008
median cost of approximately $710. HCPCS codes G0304 and G0305 are
assigned to APC 0213, with a CY 2008 median cost of approximately $145.
Table 16.--Final CY 2008 APC Reassignments of Other New Technology Procedures to Clinical APCs
----------------------------------------------------------------------------------------------------------------
CY 2007 APC Final CY
HCPCS code Short descriptor CY 2007 SI CY 2007 APC payment Final CY Final CY 2008 APC
rate 2008 SI 2008 APC median cost
----------------------------------------------------------------------------------------------------------------
19298.......... Place breast rad S......... 1524 $3,250 T........... 0648 $3,560
tube/caths.
G0302.......... Pre-op service S......... 1509 750 S........... 0209 710
LVRS complete.
G0303.......... Pre-op service S......... 1507 550 S........... 0209 710
LVRS 10-15 dos.
G0304.......... Pre-op service S......... 1504 250 S........... 0213 145
LVRS 1-9 dos.
G0305.......... Post op service S......... 1504 250 S........... 0213 145
LVRS min 6.
----------------------------------------------------------------------------------------------------------------
D. APC-Specific Policies
1. Cardiac Procedures
a. Cardiac Computed Tomography and Computed Tomographic
Angiography(APCs 0282 and 0383)
Cardiac computed tomography (CCT) and cardiac computed tomography
angiography (CCTA) are noninvasive diagnostic procedures that assist
physicians in obtaining detailed images of coronary blood vessels. The
data obtained from these procedures can be used for further diagnostic
evaluations and/or appropriate therapy for coronary patients.
Currently, there are eight Category III CPT codes that describe CCT
and CCTA procedures. The CPT codes, which were shown in Table 31 of the
proposed rule, are 0144T through 0151T. These codes were new for CY
2006. In the CY 2006 OPPS final rule with comment period, we assigned
the CCT and CCTA procedure codes to interim APCs, which were subject to
public comment. In CY 2006, the CCT and CCTA procedure codes were
assigned to four APCs, specifically, APC 0282 (Miscellaneous
Computerized Axial Tomography), APC 0376 (Level II Cardiac Imaging),
APC 0377 (Level III Cardiac Imaging), and APC 0398 (Level I Cardiac
Imaging). We did not receive any public comments on the interim APC
assignments.
In the CY 2007 OPPS/ASC proposed rule, we proposed to retain the
existing APC assignments for the CCT and CCTA procedure codes. We
received several public comments on the proposed APCs assignments,
which we addressed in the CY 2007 OPPS/ASC final rule with comment
period (71 FR 68038 and 68039). Several of the commenters requested
that we either not assign the CCT and CCTA procedures to any APCs or
assign them to appropriate New Technology APCs. In addition, some
commenters were also concerned that CCT and CCTA procedures were not
[[Page 66700]]
clinically homogeneous with other procedures assigned to APCs 0282,
0376, 0377, and 0398, noting that the last three APCs previously
contained only nuclear medicine cardiac imaging procedures.
In the CY 2007 OPPS/ASC final rule with comment period (71 FR
68038), we indicated our belief that the clinical characteristics and
expected resource use associated with the CCT and CCTA procedures were
sufficiently similar to the other procedures assigned to APCs 0282,
0376, 0377, and 0398 that we believed those APC assignments were
appropriate. While several of those APCs also contained nuclear
medicine imaging procedures, we had never designated those APCs as
specific to nuclear medicine procedures. Therefore, for CY 2007, we
continued with the CY 2006 APC assignments for CPT codes 0144T through
0151T. We did not agree with the commenters that use of CT and CTA for
cardiac studies was a new technology for which we had no relevant OPPS
cost information that could be used to estimate hospital resources for
these procedures. We also believed these services could be potentially
covered hospital outpatient services, so that it would not be
appropriate for us to depart from our standard OPPS policy and not
assign them to APCs. As we indicated in our CY 2007 OPPS/ASC 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 assigned to existing clinical APCs. 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. As we
noted in the CY 2007 OPPS/ASC final rule with comment period, we
believed that CCT and CCTA procedures were appropriate for separate
payment under the OPPS should local contractors provide coverage for
these procedures and, therefore, they warranted status indicator and
APC assignments that would provide separate payment under the OPPS (71
FR 68038).
At its March 2007 meeting, the APC Panel recommended that CMS work
with stakeholders to determine more appropriate APC placements for CCT
and CCTA procedures. The APC Panel made no specific recommendations
regarding the appropriate APC assignments for these services, although
several different clinical APC configurations were discussed, along
with the alternative of assigning these procedures to New Technology
APCs.
We note that we generally meet with interested organizations
concerning their views about OPPS payment policy issues with respect to
specific technologies or services. Following the publication of the CY
2007 OPPS/ASC final rule with comment period, we received such
information from interested individuals and organizations regarding the
clinical and facility resource characteristics of CCT and CCTA
procedures. In the CY 2008 OPPS/ASC proposed rule (72 FR 42711), we
reiterated that we would consider the input of any individual or
organization to the extent allowed by Federal law, including the
Administrative Procedure Act (APA) and the FACA. We explained that we
establish the OPPS payment rates for services through regulations,
during our annual rulemaking cycle. 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.
During the development of the CY 2008 proposed rule, we noted that
analysis of our hospital data for claims submitted for CY 2006
indicated that CCT and CCTA procedures were performed relatively
frequently on Medicare patients. Our claims data showed a total of over
16,000 procedures performed, with about 11,000 single claims available
for ratesetting. Based on our analysis of the robust hospital
outpatient claims data at that time, we believed we had adequate claims
data from CY 2006 upon which to determine the median costs of
performing these procedures and to assign them to appropriate clinical
APCs. We saw no rationale for reassigning these procedures to New
Technology APCs in CY 2008, when we had claims-based cost information
regarding these procedures, and they were clinically similar to other
procedures paid under the OPPS.
We acknowledged the concerns that had been expressed to us
regarding the clinical homogeneity of APCs 0376, 0377, and 0398, where
some of the CCT and CCTA were assigned for CY 2007 along with nuclear
medicine cardiac imaging procedures. Because we proposed to package
payment for diagnostic radiopharmaceuticals into payment for diagnostic
nuclear medicine procedures in CY 2008 as discussed in detail in
section II.A.4.c.(5) of this final rule with comment period, we
believed that to ensure the clinical and resource homogeneity of APCs
0376, 0377, and 0398 in CY 2008, it would be most appropriate to
reassign the CCT and CCTA services currently residing in those APCs to
other clinical APCs for CY 2008.
Therefore, for CY 2008, we proposed to assign the CCT and CCTA
procedures to two clinical APCs, specifically new clinical APC 0383
(Cardiac Computed Tomographic Imaging) and APC 0282, as shown in Table
17 below. The proposed median cost of approximately $314 for APC 0383
was based entirely on claims data for CPT codes 0145T, 0146T, 0147T,
0148T, 0149T, and 0150T that described CCT and CCTA services, a
clinically homogeneous grouping of services. In addition, the
individual median costs of these services ranged from a low of
approximately $277 to a high of $437, reflecting their hospital
resource similarity as well. We proposed to reassign the two other CCT
CPT codes, specifically CPT codes 0144T and 0151T, to APC 0282. The
inclusion of these two codes in APC 0282 resulted in a CY 2008 proposed
APC median cost of about $105.
We received a number of public comments concerning our CY 2008
proposals for CCT and CCTA procedures. A summary of the public comments
and our responses follow.
Comment: While several commenters expressed appreciation for the
proposed reassignment of CCT and CCTA procedures into their own
clinically homogenous APC groups, many commenters disagreed with the
proposal to reassign these services from APCs 0282, 0376, 0377, and
0398 to APCs 0282 and 0383 for CY 2008. These commenters were
especially concerned with the proposed payment rates for these
procedures and asserted that the proposed median costs of $105 for APC
0282 and $314 for APC 0383 were inadequate because they were based on
limited data, thereby undervaluing these new technology services. The
commenters further believed that the CY 2008 proposed payment rates of
$107 for APC 0282 and $318 for APC 0383 were unreasonably low based on
only 16,000 total procedures, with about 11,000 single claims used for
ratesetting. Some commenters pointed out that the
[[Page 66701]]
first year in which the new procedures were specifically reported by
hospitals was CY 2006. They argued that because it takes time for
hospitals to completely capture and report the full costs associated
with new procedures in their charges, hospitals could not have reported
these services accurately in CY 2006. One commenter believed that
because most hospitals do not specifically allocate capital costs to
the cost centers involved, the CCRs used to convert charges to costs
for CCT and CCTA procedures were likely understated.
Many commenters expressed concern that there had not been
sufficient time to develop accurate and reliable claims data for these
new procedures and that additional measures were necessary to ensure
appropriate payments. Some commenters recommended that CMS delay the
implementation of the CY 2008 median costs until a full year of claims
data were available from both multiple and single claims and suggested
that CMS continue with the CY 2007 APC assignments for CCT and CCTA
procedures. They argued that inadequate payment rates would
unintentionally encourage the use of more expensive and invasive
diagnostic procedures for Medicare beneficiaries. Some commenters
further requested that CMS consult with stakeholders and utilize
external data to determine the degree to which OPPS claims data
accurately reflected the relative resource costs of these procedures
and to make appropriate adjustments to the payment rates, especially
for APC 0383. Other commenters requested that CMS reassign the CCT and
CCTA procedures to appropriate New Technology APCs for CY 2008.
Some commenters requested that CMS reconsider the reassignment of
CPT codes 0144T and 0151T whose median costs varied significantly, from
$86 and $144, respectively, because these services did not appear to be
clinically appropriate when compared to the other procedures assigned
to APC 0282.
Response: While we acknowledge that the CPT codes for CCT and CCTA
procedures were new for January 2006, we disagree with the commenters'
argument that our claims data are inadequate to support the
reassignment of CCT and CCTA procedures to clinical APCs for CY 2008
based on hospital costs derived from claims. We used the approximately
12,000 single bills available for this final rule with comment period
in determining the median costs for the CCT and CCTA procedures because
the single bills provide us with the most accurate costs that are the
foundation of our standard OPPS ratesetting methodology. As we discuss
in section II.A.1.b. of this final rule with comment period, we are
unable to appropriately allocate packaged costs on multiple procedure
claims so we generally are not able to use them in setting payment
rates. As we also discuss in that section, we are continuing to work on
additional methodologies that would allow us to use claims data from
more OPPS claims. While we recognize that reliance on single procedure
claims may result in the use of fewer claims for some services than for
others, in the case of CCT and CCTA procedures, in particular, we were
able to use about two-thirds of all approximately 18,000 claims for
ratesetting. These services were reported by many hospitals in CY 2006,
and we have no reason to believe that costs based upon this large
percentage of all claims do not accurately reflect the resource costs
of these services to hospitals. Our standard OPPS methodology
determines the relative costs of services from claims, with a specific
focus on relative costs and not absolute costs, and we do not believe
there is any need for us to utilize external data to determine the
costs of these services. Additionally, we do not agree with the
commenters' suggestion to place the CCT and CCTA procedures in New
Technology APCs. We believe that, based on the clinical characteristics
and resource use calculated from CY 2006 claims for CCT and CCTA
procedures, our proposal would assign them to appropriate clinical APCs
for CY 2008. In fact, several commenters acknowledged that the proposed
APC assignments of these procedures were appropriate based on explicit
consideration of clinical homogeneity.
Further, in the case of CPT codes 0144T and 0151T, the commenters
mistakenly believed that the CY 2008 OPPS median costs for these
procedures were $86 and $144, respectively. The CY 2008 proposed rule
median cost for CPT code 0144T was approximately $68 and approximately
$43 for CPT code 0151T, and their final rule median costs are
approximately $68 and $54, respectively. The $86 and $144 figures
reported by some commenters were based on the procedures' mean costs,
not the median costs which are used for ratesetting under the OPPS. We
believe that CPT codes 0144T and 0151T are appropriately assigned to
APC 0282 as their median costs fall within the range of costs of other
procedures also assigned to the APC, which has a final median cost of
approximately $100.
Comment: Some commenters were uncertain as to whether the costs of
the contrast agents used in conjunction with CCT and CCTA procedures
were included in the proposed payment rate calculations for APCs 0282
and 0383. They requested that CMS address this issue in this final rule
with comment period. The commenters requested that CMS increase the
payment rates for APCs 0282 and 0383 if the costs of the contrast
agents were not included in the proposed payment rates.
Response: The proposed payment rates for APCs 0282 and 0383
included the costs of the contrast agents, because, as discussed
further in section II.A.4.c.(6) of this final rule with comment period,
we proposed to package payment for all contrast agents for CY 2008. Our
final CY 2008 policy packages payment for all contrast agents and,
therefore, the final payment rates for CCT and CCTA procedures include
these costs.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to assign CCT
and CCTA procedures to APCs 0282 and 0383, with CY 2008 median costs of
approximately $100 and approximately $296, respectively. The final CY
2008 APC assignments and APC median costs for the specific CCT and CCTA
procedures are displayed in Table 17.
Table 17.--Final CY 2008 APC Assignments of CCT and CCTA Procedures
----------------------------------------------------------------------------------------------------------------
Final CY
HCPCS code Short descriptor CY 2007 SI CY 2007 CY 2007 APC Final CY 2008 Final CY 2008 APC
APC median cost SI 2008 APC median cost
----------------------------------------------------------------------------------------------------------------
0144T.......... CT heart wo dye; S.......... 0398 $252 S............. 0282 $100
qual calc.
0145T.......... CT heart w/wo S.......... 0376 305 S............. 0383 296
dye funct.
0146T.......... CCTA w/wo dye... S.......... 0376 305 S............. 0383 296
0147T.......... CCTA w/wo, quan S.......... 0376 305 S............. 0383 296
calcium.
0148T.......... CCTA w/wo, strxr S.......... 0377 397 S............. 0383 296
[[Page 66702]]
0149T.......... CCTA w/wo, strxr S.......... 0377 397 S............. 0383 296
quan calc.
0150T.......... CCTA w/wo, S.......... 0398 252 S............. 0383 296
disease strxr.
0151T.......... CT heart funct S.......... 0282 94 S............. 0282 100
add-on.
----------------------------------------------------------------------------------------------------------------
b. Coronary and Non-Coronary Angioplasty (PTCA/PTA) (APCs 0082, 0083,
and 0103)
For CY 2008, we proposed to delete APC 0081 (Noncoronary
Angioplasty or Atherectomy) as a result of the effects of the proposed
CY 2008 packaging approach on median costs (see section II.A.4.c. of
this final rule with comment period for more discussion of our
packaging approach). We proposed to reassign the procedures that mapped
to this APC in CY 2007 to APCs that would be homogeneous with respect
to clinical characteristics and resource use in CY 2008, specifically
APCs 0082 (Coronary or Non-Coronary Atherectomy), 0083 (Coronary or
Non-Coronary Angioplasty and Percutaneous Valvuloplasty), and 0103
(Miscellaneous Vascular Procedures). The CY 2008 proposed payment rates
for these APCs were approximately $5,654, $2,934, and $972,
respectively. The CY 2007 payment rate for APC 0081 was approximately
$2,639.
We received one public comment on our CY 2008 proposal to delete
APC 0081 and reassign the procedures that mapped to this APC to APCs
0082 and 0083. A summary of the public comment and our response follow.
Comment: One commenter stated that the proposed reassignment of
some of the angioplasty procedures assigned to APC 0081 in CY 2007 to
APC 0083 in CY 2008 fails to recognize the differences in median costs
associated with the use of specialty balloons in certain coronary and
non-coronary angioplasty (PTCA/PTA) procedures. According to the
commenter, specialty balloons are defined as balloons that can be used
for purposes other than inflation and deflation (eg, cutting balloons
and cold therapy balloons). The commenter estimated from an analysis of
the CY 2006 Medicare claims data that the median costs for PTCA/PTA
procedures involving specialty balloons are approximately 55 percent
higher than the median costs of all PTCA/PTA procedures in APC 0083,
and represent approximately 4 percent of the cases. The commenter
expressed concern that inadequate payment for PTCA/PTA procedures
involving specialty balloons could reduce beneficiary access to this
technology.
The commenter urged CMS to reconsider its proposal to reassign all
PTCA/PTA procedures to APC 0083. Specifically, the commenter requested
that CMS establish a HCPCS Level II G-code to differentiate coronary
and noncoronary PTCA/PTA procedures using specialty balloons from those
PTCA/PTA procedures using standard, nonspecialty balloons, defining
specialty balloons as those which have a median reported cost of more
than $800 based on CY 2006 hospital claims containing the Level II
HCPCS C-code for PTCA/PTA balloons, C1725 (Catheter, transluminal
angioplasty, non-laser). The commenter stated that nonspecialty
balloons cost approximately $200 to $400. According to the commenter's
suggestion, the new G-code would map to a new APC for coronary and
noncoronary angioplasty procedures using specialty balloons, the
payment for which would be based upon the median cost of procedures
performed using specialty balloons, as indicated on CY 2006 claims by
the reporting of C1725 where the reported catheter cost is more than
$800.
Response: We believe that the proposed reassignment of the
procedures assigned to APC 0081 in CY 2007 to APC 0083 in CY 2008 is
appropriate, both in terms of the clinical similarities and resource
costs of the procedures involved. The HCPCS-specific median costs of
significant procedures assigned to APC 0083 range from approximately
$2,621 to $4,339. Even considering the information provided by the
commenter about the expected differential cost between specialty and
non-specialty balloons of $400 to $600, we would not expect Medicare
beneficiaries to have problems with access to procedures with specialty
balloons, when the APC 0083 CY 2008 median cost is approximately
$2,855. Packaging payment for the variety of implantable devices that
are used in specific procedures is a well-established principle of the
OPPS, and we expect that hospitals will carefully consider the clinical
benefits and costs of all technologies when performing procedures on
patients. Therefore, we also believe that a policy to provide different
payments for PTCA/PTA procedures involving specialty balloons would not
be consistent with our overall strategy to encourage hospitals to use
resources more efficiently by increasing the size of the payment
bundles. If the use of a very expensive device in a clinical scenario,
such as a specialty balloon, caused a specific procedure to be much
more expensive for the hospital than the APC payment, we consider such
a case to be the natural consequence of a prospective payment system
that anticipates that some cases will be more costly and others less
costly than the procedure payment. We will continue to monitor the
costs of PTCA/PTA procedures over time based on the evolution of
clinical practice and will consider proposing future modifications to
the configuration of APC 0083 as necessary.
After consideration of the public comment received, we are
finalizing our CY 2008 proposal, without modification, to reassign
angioplasty procedures assigned to APC 0081 in CY 2007 to APC 0083 in
CY 2008. The median cost of APC 0083 is approximately $2,855.
c. Implantation of Cardioverter-Defibrillators (APCs 0107 and 0108)
In CY 2003, we created four Level II HCPCS codes for implantation
of single and dual chamber cardioverter-defibrillators (ICDs) with and
without leads because, for the CY 2004 OPPS, we deleted the device
HCPCS codes and there was no other way of determining whether the
device being implanted was a single chamber or dual chamber device. We
were concerned that the costs of inserting single versus dual chamber
ICDs could be sufficiently different due to the two types of devices
implanted such that separate APC assignments for the insertion
procedures could be appropriate in the future. The HCPCS codes are
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
[[Page 66703]]
defibrillator and insertion of pulse generator); and G0300 (Insertion
or repositioning of electrode lead for dual chamber pacing cardioverter
defibrillator and insertion of pulse generator). The pairs of codes
were assigned to two different clinical APCs, depending on whether or
not they included the possibility of electrode insertion, specifically
APC 0107 (Insertion of Cardioverter-Defibrillator) and APC 0108
(Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads).
In the same year, the OPPS ceased to recognize for payment the two
CPT codes for insertion of ICDs with or without ICD leads. These CPT
codes are 33240 (Insertion of single or dual chamber pacing
cardioverter-defibrillator pulse generator) and 33249 (Insertion or
repositioning of electrode lead(s) for single or dual chamber pacing
cardioverter-defibrillator and insertion of pulse generator).
We reinstated the device category HCPCS codes on January 1, 2005.
Moreover, since January 1, 2005, hospitals have been required to report
devices they use or implant when there is a device code that describes
the device. We began to edit to ensure that hospitals are correctly
billing devices required for certain procedures in April 2005 and
implemented the second phase of device edits on October 1, 2005.
Therefore, we no longer need different procedural Level II HCPCS codes
to identify whether hospitals inserted a single or dual chamber ICD
device.
At its March 2007 meeting, the APC Panel recommended that CMS
delete the Level II HCPCS codes for implantation of cardioverter-
defibrillator pulse generators with or without repositioning or
implantation of electrode lead(s) for CY 2008 and authorize hospitals
to report the CPT codes. The APC Panel indicated that the requirement
for reporting device codes would enable CMS to continue to identify
costs when different types of devices are implanted if that were to be
necessary.
We analyzed the median cost data associated with APCs 0107 and 0108
as part of our preparation for the APC Panel discussion. While there
was a difference in the median cost when a single chamber versus a dual
chamber device is implanted, the difference has never been great enough
to justify differential APC assignments for the procedures. Table 34
included in the CY 2008 OPPS/ASC proposed rule presented a historical
summary of all single claim median costs. (For purposes of this
analysis, we displayed the median costs for all single claims without
regard to adjustment or to whether the claims met various selection
criteria; these were not the median costs on which proposed payments
were based.)
Hospitals have consistently indicated that they would prefer to
report services furnished using the CPT codes that describe them,
rather than the Level II HCPCS G-codes, because many private payers
require that they bill the CPT codes. We also prefer to recognize CPT
codes for procedures under the OPPS, when possible, to minimize the
administrative coding burden on hospitals.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42715), we stated our
belief that the differences between the median costs for the two Level
II HCPCS codes assigned to each APC (that is, G0297 and G0298 for APC
0107 and G0299 and G0300 for APC 0108) do not currently support
differential APC assignments for single and dual chamber ICD insertion
procedures. The required device coding would allow us to continue to
follow the different costs over time by examining subsets of ICD
implantation procedure claims based on the type of device reported on
the claims. Moreover, we are sensitive to the benefits of minimizing
the reporting burden on hospitals. Therefore, for CY 2008, we proposed
to delete the Level II HCPCS codes for ICD insertion procedures and
require hospitals to bill the appropriate CPT codes, along with the
applicable device C-codes, for payment under the OPPS.
We received a number of public comments on our CY 2008 proposal for
reporting ICD implantation procedures under the OPPS. A summary of the
public comments and our responses follow.
Comment: Several commenters supported implementing the policy as
proposed. One commenter favored the elimination of the Level II HCPCS
codes for ICD implantation, citing the administrative burden these pose
for hospitals, but remained concerned about the potential negative
impact to hospitals when the more expensive dual chamber device is used
for Medicare beneficiaries. The commenter suggested that CMS should
consider creation of composite APCs for device-dependent procedures,
such as ICD implantation, where the device costs can vary significantly
based on the type of device used. The commenter suggested that payment
for these composite APCs would be based on the combination of the
device implantation CPT code and the existing Level II HCPCS code for
the particular device. According to the commenter, this would minimize
the administrative burden for providers, allow coding to remain
consistent across payers, and enable more appropriate payment for
procedures with varying device costs.
Response: Composite APCs provide a single payment for two or more
major procedures that are commonly performed together, in order to
promote efficiency by increasing the size of the payment bundle. We do
not agree that the payment methodology outlined by one commenter, to
base payment for ICDs on the combination of the ICD implantation CPT
code and the existing device code, is consistent with the concept of
composite APCs as described in the proposed rule and as finalized in
section II.A.4.d. of this final rule with comment period. The scenario
described by the commenter largely describes the current packaging of
device payment into the payment for the procedure, except that we
generally base payment on all of the devices associated with a
procedure as a mechanism to promote the efficient utilization of
resources. The recommended approach could actually reduce packaging
under the OPPS by creating small and more specific payment bundles,
rather than increasing the size of the payment bundles to provide
hospitals with the flexibility to manage their resources as they
control costs. To establish a separate APC for each combination of a
procedure and a particular device used, as described by the commenter,
would create incentives for the use of the most expensive device rather
than creating incentives for efficiency and therefore is contrary to
the principles of a prospective payment system. As described above, we
believe that the payment for the procedures and associated devices
included in APCs 0107 and 0108 is appropriate, as the differences
between the median costs for the two Level II HCPCS codes currently
assigned to each APC do not currently support differential APC
assignments for single and dual chamber ICD insertion procedures.
After consideration of the public comments received, we are
adopting the March 2007 APC Panel recommendation and finalizing our CY
2008 proposal, without modification, to delete the Level II HCPCS codes
(G0297, G0298, G0299, and G0300) for ICD insertion procedures and
require hospitals to bill the appropriate CPT codes for ICD insertion,
specifically CPT code 33240 or CPT code 33249, as appropriate, along
with the applicable device C-codes, for payment under the OPPS in CY
2008.
[[Page 66704]]
d. Removal of Patient-Activated Cardiac Event Recorder (APC 0109)
In the CY 2008 OPPS/ASC proposed rule, we proposed to continue our
CY 2007 assignment of CPT code 33284 (Removal of an implantable,
patient-activated cardiac event recorder) to APC 0109 (Removal/Repair
of Implanted Devices), with a proposed CY 2008 payment rate of
approximately $389. The CY 2007 payment rate for this service is
approximately $676.
We received one public comment on the CY 2008 proposed
reconfiguration of APC 0109. A summary of the public comment and our
response follow.
Comment: One commenter requested that CMS reexamine its proposed
assignment of CPT code 33284 to APC 0109 in light of the proposed
reassignment of CPT codes 36575 (Repair of tunneled or non-tunneled
central venous access catheter, without subcutaneous port or pump,
central or peripheral insertion site) and 36589 (Removal of tunneled
central venous catheter, without subcutaneous port or pump) from APC
0621 (Level I Vascular Access Procedures) to APC 0109 for CY 2008. The
commenter asserted that the proposed inclusion of CPT codes 36575 and
36589 in APC 0109 significantly altered the proposed median cost of APC
0109, to the extent that it was no longer representative of the
resource requirements of CPT code 33284. The commenter requested that
CMS create a separate APC for CPT code 33284 if CMS finalizes its
proposal to reassign CPT codes 36575 and 36589 to APC 0109.
Response: We agree with the commenter that the change in
composition of APC 0109 may no longer most accurately reflect the
resource characteristics of CPT code 33284. CPT codes 36575 and 36589
have median costs of approximately $319 and $357, respectively, while
CPT code 33284 has a median cost of approximately $682. While we
appreciate the commenter's suggestion for a new APC for CPT code 33284,
we believe that an existing clinical APC may sufficiently account for
the clinical and resource characteristics of the procedure described by
CPT code 33284. The clinical characteristics of CPT code 33284 are
similar to those procedures in APC 0020 (Level II Excision/Biopsy). CPT
code 33284 and the other procedures assigned to APC 0020 generally
require surgical incisions, local anesthesia, and suturing. In
addition, we believe that APC 0020, with an APC median cost of
approximately $546, more closely aligns with the resources of CPT code
33284, rather than its proposed assignment to APC 0109, with an APC
median cost of approximately $356.
After consideration of the public comment received, we are not
finalizing our CY 2008 proposal to assign CPT code 33284 to APC 0109.
Instead, we are reassigning CPT code 33284 to APC 0020 for CY 2008,
with a median cost of approximately $546.
e. Stress Echocardiography (APC 0697)
In the CY 2008 OPPS/ASC proposed rule, we proposed to assign CPT
code 93350 (Echocardiography, transthoracic, real-time with image
documentation (2D), with or without M-mode recording, during rest and
cardiovascular stress test using treadmill, bicycle exercise and/or
pharmacologically induced stress, with interpretation and report) to
APC 0697 (Level I Echocardiogram, Except Transesophageal), with a
proposed payment rate of approximately $306. Currently, this service is
assigned to APC 0269 (Level II Echocardiogram Except Transesophageal),
with a payment rate of approximately $198 for CY 2007. The proposed
packaging approach for CY 2008, as described further in section
II.A.4.c. of this final rule with comment period, proposed to package
significant additional costs for ancillary and supportive services into
the CY 2008 payment for CPT code 93350.
We received a few public comments concerning our CY 2008 proposed
reassignment of CPT code 93350 to APC 0697. A summary of the public
comments and our response follow.
Comment: A few commenters requested that we continue to assign CPT
code 93350 to APC 0269, instead of reassigning this procedure to APC
0697 as proposed. The commenters stated that the Level II APC is a more
appropriate placement, as the procedure is comparable in clinical and
resource characteristics to CPT code 93307 (Echocardiography,
transthoracic, real-time with image documentation (2D) with or without
M-mode recoding; complete) that CMS proposed to retain in APC 0269.
Response: We have a significantly greater number of single and
``pseudo'' single claims available for CPT code 93350 for this final
rule with comment period than we had for the proposed rule because, in
response to the request of commenters, we added CPT code 93017
(Cardiovascular stress test using maximal or submaximal treadmill or
bicycle exercise, continuous electrocardiographic monitoring, and/or
pharmacological stress; tracing only, without interpretation or report)
to the final CY 2008 bypass list, as described in section II.A.1.b. of
this final rule with comment period. By adding CPT code 93017 to the CY
2008 bypass list, we did not attribute any packaged services that may
be on the claim to this procedure, and we were therefore able to create
single and ``pseudo'' single claims from claims that would have
otherwise been considered multiple procedure claims. The availability
of additional claims for ratesetting and our final policy for paying
for contrast and nonconstrast echocardiography through different APCs
also contribute to the differences between the final rule median costs
and the proposed rule median costs for echocardiography CPT codes.
For CY 2008, we are establishing a new APC for echocardiograms with
contrast as described in section II.A.4.c.(6) of this final rule with
comment period, specifically APC 0128 (Echocardiogram with Contrast).
The median cost of CPT code 93350 for contrast studies is approximately
$527, while the median cost of CPT code 93307 for contrast studies is
approximately $545. When these studies are performed with contrast in
CY 2008, they will be reported with HCPCS codes C8928 (Transthoracic
echocardiography with contrast, real-time with image documentation
(2D), with or without M-mode recording, during rest and cardiovascular
stress test using treadmill, bicycle exercise and/or pharmacologically
induced stress, with interpretation and report); and C8923
(Transthoracic echocardiography with contrast, real-time with image
documentation (2D) with or without M-mode recording; complete),
respectively. Both of these C-codes are assigned to new APC 0128 based
on their clinical and resource comparability, with a CY 2008 median
cost of approximately $534.
For this final rule with comment period, we have over 88,000 single
bills for noncontrast studies reported with CPT code 93350 that have an
updated median cost of approximately $374. This median cost is quite
close to the final rule median cost of CPT code 93307 for noncontrast
studies of approximately $404. We agree with the commenters that CPT
code 93350 for noncontrast studies is more appropriately placed in the
Level II noncontrast APC that has a median cost of approximately $401,
and where CPT code 93307 is also assigned. The two procedures are
clinically similar, both representing comprehensive transthoracic
echocardiography services.
Therefore, after consideration of the public comments received, we
are not
[[Page 66705]]
finalizing our proposal to assign noncontrast studies reported with CPT
code 93350 to APC 0697, which has the new APC title of ``Level I
Echocardiogram Without Contrast Except Esophageal''. Instead, we are
retaining the assignment of CPT code 93350 for noncontrast studies to
APC 0269, which has the new APC title of ``Level II Echocardiogram
Without Contrast Except Transesophageal,'' because we believe this
procedure is clinically similar to other procedures in the Level II APC
and the median costs indicate that the noncontrast studies in this APC
require similar hospital resources as well. Contrast studies reported
with the corresponding C-code to CPT code 93350, specifically C8928,
are assigned to APC 0128, with a CY 2008 median cost of approximately
$534.
f. Coronary or Non-Coronary Atherectomy (APC 0082)
Currently, APC 0082 is titled ``Coronary Atherectomy'' and contains
only two CPT codes: 92995 (Percutaneous transluminal coronary
atherectomy, by mechanical or other method, with or without balloon
angioplasty; single vessel) and 92996 (Percutaneous transluminal
coronary atherectomy, by mechanical or other method, with or without
balloon angioplasty; each additional vessel (List separately in
addition to code for primary procedure)). We proposed to reconfigure
APC 0082 for the CY 2008 OPPS by adding 11 CPT codes, most of which
were for percutaneous atherectomy procedures, and to change its title
to ``Coronary or Non-Coronary Atherectomy'', as shown in Addendum A to
the proposed rule (72 FR 42838), to better reflect the composition of
procedures that we proposed to assign to this APC. The CY 2008 proposed
payment rate for APC 0082 was approximately $5,654, while its CY 2007
payment rate is approximately $4,438.
We received one public comment on the CY 2008 proposed
reconfiguration of APC 0082. A summary of the public comment and our
response follow.
Comment: A commenter objected to the proposed composition of APC
0082 on the basis that it includes both coronary and noncoronary
atherectomy procedures, as a result of the proposed packaging of
imaging supervision and interpretation CPT codes. The commenter stated
that, as proposed, APC 0082 no longer contains services that are
comparable clinically and with respect to resource use and, therefore,
believed that the coronary and noncoronary services should not be
assigned to the same APC. The commenter indicated that treatment of
peripheral vascular disease is more diffuse, requires a different
approach, and utilizes different resources than treatment of coronary
disease. The commenter noted that it could not determine if the
proposed payment rate for APC 0082 is appropriate, due to the proposed
packaging of imaging supervision and interpretation codes for the
noncoronary atherectomy procedures, and questioned whether the claims
data could accurately reflect the costs associated with these different
procedures.
Response: We believe that there is sufficient clinical homogeneity
among all the services that we proposed to assign to APC 0082 for the
CY 2008 OPPS and that the resources that those services require are
sufficiently similar to justify assigning coronary and noncoronary
atherectomy procedures to the same clinical APC. The CY 2006 claims
data show that CPT codes 92995 and 92996 are very uncommon services in
the HOPD, as they have a total combined frequency of 159 services for
CY 2006. Moreover, the median costs for these codes (approximately
$5,696 for CPT code 92995 and $3,924 for CPT code 92996) are very
comparable to the median costs for the two highest volume noncoronary
atherectomy codes in APC 0082: CPT code 35493 (Transluminal peripheral
atherectomy, percutaneous; femoral-popliteal), which has a total
frequency of 8,473 and a median cost of approximately $5,956; and CPT
code 37204 (Transcatheter occlusion or embolization (e.g., for tumor
destruction, to achieve hemostasis, to occlude a vascular
malformation), percutaneous, any method, non-central nervous system,
non-head or neck), which has a total frequency of 5,789 and a median
cost of approximately $4,867. The CY 2008 OPPS median cost for APC 0082
(with correct devices, no token claims, and no claims with the ``FB''
modifier) is approximately $5,506 and the total frequency of services
in the APC is 18,357.
There are no HCPCS codes in APC 0082, as proposed, that would cause
the APC to violate the 2 times rule. We believe that it is appropriate
to reassign the noncoronary atherectomy procedures to APC 0082 because
we believe that the clinical characteristics and resource costs are
sufficiently similar to warrant their placement in the same APC with
coronary atherectomy procedures. We recognize that the similar resource
costs may result, to some extent, from the packaging of guidance and
imaging supervision and interpretation services under the CY 2008 OPPS.
However, even absent our proposal to increase packaging for the CY 2008
OPPS, the median cost of virtually all codes for procedural services
contains some costs for packaged services. Moreover, the movement of
codes from one APC to another occurs for a variety of reasons,
including changes in packaging from one year to another. In addition,
as discussed further in section II.A.2. of this final rule with comment
period, we proposed to reconfigure certain clinical APCs for CY 2008 as
a way to promote stability and appropriate payment for the services
assigned to them, including low total volume APCs, with a particular
focus on APCs with total frequencies of less than 1,000. APC 0082, as
configured for CY 2007, includes only 232 services. Therefore, the
reconfiguration of APC 0082 for CY 2008, as a result of increased costs
that occur with more packaging and our effort to minimize the number of
low volume APCs, among other reasons, is a normal occurrence in the
course of updating the OPPS from one year to another.
After consideration of the public comment received, we are
finalizing our CY 2008 proposal, without modification, to reconfigure
APC 0082 as proposed, with a median cost of approximately $5,506.
2. Gastrointestinal Procedures
a. Computed Tomographic Colonography (APC 0332)
For CY 2008, we proposed to reassign diagnostic computed
tomographic colonography, specifically described by CPT code 0067T
(Computed tomographic (CT) colonography (i.e., virtual colonoscopy);
diagnostic), from APC 0333 (Computed Tomography without Contrast
followed by Contrast) to APC 0332 (Computed Tomography without
Contrast), with a proposed payment rate of approximately $201.
We received several public comments concerning this proposal. A
summary of the public comments and our response follow.
Comment: Several commenters requested that CMS continue the CY 2007
APC assignment for CPT code 0067T, specifically APC 0333, rather than
reassign it to APC 0332 for CY 2008 as proposed.
Response: CPT code 0067T was implemented on January 1, 2005, and
initially assigned to APC 0332. As part of our annual APC review
process, we subsequently reassigned CPT code 0067T to APC 0333 in CY
2006 and continued this APC assignment in CY 2007. Based on analysis of
the CY 2006
[[Page 66706]]
hospital outpatient claims data, we proposed to reassign CPT code 0067T
to APC 0332 for CY 2008 based on clinical homogeneity and resource
considerations. Specifically, our hospital outpatient claims data from
CY 2006 showed a median cost of approximately $164 for CPT code 0067T
based on 1,421 single claims (of 1,904 total claims). Based on the
median costs of the significant procedures assigned to APC 0332 for CY
2008, which range from $164 to $227, we believe that CPT code 0067T
most closely resembles other noncontrast CT procedures also assigned to
APC 0332. We do not agree with the commenters' recommendation that APC
0333 is the most appropriate APC assignment for CPT code 0067T because
the median cost of approximately $322 for APC 0333, which contains
significant procedures with HCPCS-specific median costs ranging from
about $272 to $359, is much higher than the median cost of CPT code
0067T. In addition, as discussed in section II.A.4.c. of this final
rule with comment period, we are finalizing our proposal to package
payment for all contrasts agents in CY 2008. Because the CT scans
assigned to APC 0333 for CY 2008 all include the administration of
contrast and CT colonography is a noncontrast study, we believe 0067T
is most appropriately assigned to APC 0332, where other noncontrast CT
scans reside.
After consideration of the public comments received, we are
finalizing, without modification, the proposed assignment of CPT code
0067T to APC 0332, with a median cost of about $189 for CY 2008.
b. Laparoscopic Neurostimulator Electrode Implantation (APC 0130)
In the CY 2008 OPPS/ASC proposed rule, we proposed to continue our
CY 2007 assignment of CPT code 43647 (Laparoscopy, surgical;
implantation or replacement of gastric neurostimulators electrodes,
antrum) to APC 0130 (Level I Laparoscopy), with a proposed payment rate
of approximately $2,217. CPT code 43647 was a new code for CY 2007, so
it received an interim final CY 2007 assignment to APC 0130, with a
payment rate of approximately $1,975. In addition, during the September
2007 meeting of the APC Panel, the Panel recommended that CMS
reevaluate its decision to assign the device-dependent procedure
described by CPT code 43647 to APC 0130 because the procedure requires
a device and APC 0130 is not a device-dependent APC. We accepted the
APC Panel recommendation and reassessed the proposed CY 2008 APC
assignment of CPT code 43647 for this final rule with comment period.
We respond to this recommendation below.
We received a number of public comments on our interim final CY
2007 and proposed CY 2008 assignments of CPT code 43647 to APC 0130,
both on the CY 2007 OPPS/ASC final rule with comment period and on the
CY 2008 OPPS/ASC proposed rule. A summary of the public comments and
our response follow.
Comment: A few commenters objected to our assignment of CPT code
43647 to APC 0130, stating that APC 0130 does not accurately reflect
the clinical and cost characteristics of CPT code 43647. The commenters
noted that APC 0130 includes procedures for implanting minor devices
that have modest costs, while the laparoscopic implantation of gastric
neurostimulator electrodes is an invasive procedure that is comparable
to the surgical implantation of neurostimulator electrodes via incision
or laminectomy procedures that are assigned to APC 0061 (Laminectomy or
Incision for Implantation of Neurostimulator Electrodes, Excluding
Cranial Nerve). The commenters requested that we assign CPT code 43647
to APC 0061, which they believed more accurately reflects the clinical
and resource aspects of this procedure. In addition, the commenters
noted that if CPT code 43647 is reassigned to APC 0061, then all
peripheral neurostimulator lead implantations would be assigned to the
same APC.
Response: We have no hospital claims data for CPT code 43647
because the code was new for CY 2007. However, we agree with the
commenters that CPT code 43647 would be expected to have device costs
that are similar to other procedures assigned to APC 0061 for CY 2007
because all of these procedures implant neurostimulator electrodes. In
particular, the device percentage of device-dependent APC 0061 is about
60 percent, so that assignment of CPT code 43647 to an APC in the
laparoscopic APC series as proposed may not provide the most
appropriate payment for the procedure. While CPT code 43647 involves a
different surgical approach to neurostimulator electrode implantation,
in comparison with the potentially more invasive procedures currently
assigned to APC 0061, we still believe the procedure's clinical
characteristics more closely resemble the other procedures assigned to
APC 0061 than the minimally invasive percutaneous neurostimulator
electrode implantation procedures assigned to APC 0040 (Percutaneous
Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve).
Therefore, we agree with commenters that APC 0061 would be an
appropriate APC assignment for CPT code 43647 for CY 2008, taking into
account the procedure's clinical characteristics and expected hospital
resource costs. We will reassign CPT code 43647 to APC 0061 for CY
2008, while we await the opportunity to review its CY 2007 claims data
in preparation for the CY 2009 rulemaking cycle.
After consideration of the public comments received, we are not
finalizing our CY 2008 proposal to assign CPT code 43647 to APC 0130.
Instead, we will reassign CPT code 43647 to APC 0061, with a median
cost of approximately $5,213. In addition, we are changing the title of
APC 0061 to ``Laminectomy, Laparoscopy, or Incision for Implantation of
Neurostimulator Electrodes, Excluding Cranial Nerve'' to better reflect
all of the procedures assigned to the APC for CY 2008.
c. Screening Colonoscopies and Screening Flexible Sigmoidoscopies (APCs
0158 and 0159)
Since the implementation of the OPPS in August 2000, screening
colonoscopies and screening flexible sigmoidoscopies have been paid
separately. In the CY 2007 OPPS/ASC final rule with comment period (71
FR 68013), we implemented certain changes associated with colorectal
cancer screening services provided in HOPDs. First, 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 no longer applies. This provision applies to services
furnished on or after January 1, 2007. Second, sections 1834(d)(2) and
(d)(3) of the Act require Medicare to pay the lesser of the ASC or OPPS
payment amount for screening flexible sigmoidoscopies and screening
colonoscopies. 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 have slightly exceeded the CY 2007 ASC payment of
$446 for these procedures. Consistent with the requirements set forth
in sections 1834(d)(2) and (d)(3) of the Act, the OPPS payment rates
for HCPCS codes G0105 and G0121 were set equal to the CY 2007 ASC rate
of $446 effective January 1, 2007. This requirement did not impact the
OPPS payment rate for
[[Page 66707]]
screening flexible sigmoidoscopies (G0104, Colorectal cancer screening;
flexible sigmoidoscopy) because Medicare did not make payment to ASCs
for screening flexible sigmoidoscopies in CY 2007, so there was no
payment comparison to be made for those services.
According to the policy for the revised ASC payment system as
described in the August 2007 final rule for the revised ASC payment
system (72 FR 42493), ASCs will be paid for screening colonoscopies
based on their ASC payment weights derived from the related OPPS APC
payment weights and multiplied by the final ASC conversion factor (the
product of the OPPS conversion factor and the ASC budget neutrality
adjustment). As an office-based procedure added to the ASC list of
covered surgical procedures for CY 2008, ASC payment for screening
flexible sigmoidoscopies will be capped at the CY 2008 MPFS nonfacility
practice expense amount (72 FR 42511). Sections 1834(d)(2) and (d)(3)
of the Act would then require that the CY 2008 OPPS payment rates for
these procedures be set equal to their significantly lower ASC payment
rates.
However, for CY 2008, we proposed to use the equitable adjustment
authority of section 1833(t)(2)(E) of the Act to adjust the OPPS
payment rates for screening colonoscopies and screening flexible
sigmoidoscopies. Section 1833(t)(2)E) of the Act provides that the
Secretary shall establish adjustments, in a budget neutral manner, as
determined to be necessary to ensure equitable payments under the OPPS.
Sections 1834(d)(2) and (d)(3) of the Act regarding payment for
screening flexible sigmoidoscopies and screening colonoscopies under
the OPPS and ASC payment systems were established by Congress in 1997,
many years prior to the CY 2008 initial implementation of the revised
ASC payment system. The payment policies of the revised ASC payment
system, as summarized in section XVI.C. of this final rule with comment
period, make fundamental changes to the methodology for developing ASC
payment rates based on certain principles, specifically that the OPPS
payment weight relativity is applicable to ASC procedures and that ASC
costs are lower than HOPD costs for providing the same procedures, that
contradict the original assumptions underlying these provisions.
According to the findings of the GAO in its report, released on
November 30, 2006 and entitled ``Medicare: Payment for Ambulatory
Surgical Centers Should Be Based on the Hospital Outpatient Payment
System'' (GAO-07-86), the payment groups of the OPPS accurately reflect
the relative costs of procedures performed in ASCs just as well as they
reflect the relative costs of the same procedures provided in HOPDs.
Screening colonoscopies were among the top 20 ASC procedures in terms
of volume whose costs were specifically studied by the GAO in its work
that led to this conclusion. We see no clinical or hospital resource
explanation why the OPPS relative costs from CY 2006 OPPS claims data
for screening flexible sigmoidoscopies and screening colonoscopies
would not provide an appropriate basis for establishing their payment
rates under both the OPPS and the revised ASC payment system, according
to the standard ratesetting methodologies of each payment system for CY
2008. If we were to pay for these screening procedures under the OPPS
according to their ASC rates in CY 2008, we would significantly distort
their payment relativity in comparison with other OPPS services. We
believed and continue to believe it would be inequitable to pay these
screening services in HOPDs at their ASC rates for CY 2008, thereby
ignoring the relativity of their costs in comparison with other OPPS
services which have similar or different clinical and resource
characteristics. Therefore, for CY 2008 when we will be paying for
screening colonoscopies and screening flexible sigmoidoscopies
performed in ASCs based upon their standard revised ASC payment rates,
we proposed to adjust the payment rates under the OPPS to pay for the
procedures according to the standard OPPS payment rates. We believed
that the application of sections 1834(d)(2) and (d)(3) of the Act
produces inequitable results because of the revised ASC payment system
to be implemented in CY 2008. We believed this proposal would provide
the most appropriate payment for these procedures in the context of the
contemporary payment policies of the OPPS and the revised ASC payment
system.
We received several public commenters concerning this proposal. A
summary of the public comments and our response follow.
Comment: Several commenters agreed that it would be inequitable to
pay for screening colonoscopies and screening flexible sigmoidoscopies
services in the HOPD at their lower ASC payment rate. They supported
CMS's use of the equitable adjustment authority to adjust the OPPS
payment rates for these services.
Response: We appreciate commenters' support of our proposal. We
acknowledge that sections 1834(d)(2) and (d)(3) of the Act would
otherwise require that the CY 2008 OPPS payment rates for screening
colonoscopies and screening flexible sigmoidoscopies be set equal to
their significantly lower ASC payment rates. However, we continue to
believe it is necessary to invoke the equitable adjustment authority
provided by section 1833(t)(2)(E) of the Act to adjust the OPPS payment
rates for these procedures in order to establish the most appropriate
payment for these procedures in the context of the contemporary payment
policies of the OPPS and the revised ASC payment system.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to pay for
screening colonoscopies and screening flexible sigmoidoscopies under
the OPPS at payment rates developed according to the standard OPPS
ratesetting methodology.
3. Genitourinary Procedures
a. Cystoscopy With Stent (APC 0163)
For CY 2008, we proposed to continue assignment of CPT code 52282
(Cystourethroscopy, with insertion of urethral stent) to APC 0163
(Level IV Cystourethroscopy and other Genitourinary Procedures), with a
proposed payment rate of approximately $2,351. Payment for APC 0163 in
CY 2007 is approximately $2,147.
We received one public comment on our CY 2008 proposed assignment
of CPT code 52282 to APC 0163. A summary of the public comment and our
response follow.
Comment: One commenter indicated that the procedure described by
CPT code 52282 is inappropriately assigned to APC 0163, and that it
should be reassigned to a new device-dependent APC for CY 2008.
According to the commenter, the procedure described by CPT code 52282
is dissimilar to the other procedures that map to APC 0163, both
clinically and in terms of cost. The commenter stated that this
procedure is the only procedure in APC 0163 that involves an implant.
In addition, the commenter asserted that the APC's CY 2008 proposed
payment of approximately $2,351 is inadequate to cover hospitals' costs
for performing this procedure, and that as a result, hospitals may
limit beneficiary access to this treatment. According to the commenter,
the urethral stent that is placed during these procedures is
approximately $4,200. The commenter also noted that other stent
placement procedures have device-dependent
[[Page 66708]]
status so that adequate costs can be tracked. The commenter recommended
that CMS create a new device-dependent APC for CPT code 52282 with a
payment rate of at least $4,000.
Response: In response to the concerns raised by the commenter, we
reviewed the clinical characteristics and hospital costs from CY 2006
claims data for all procedures proposed for CY 2008 assignment to APC
0163. The APC median cost is approximately $2,270, while CPT code 52282
has a median cost of approximately $2,016, based on 291 single claims
out of a total of 900 claims for the procedure. Because of the
commenter's concern about whether the stent costs were appropriately
reflected in the procedure's median cost, we compared the median costs
of CY 2006 claims that include both CPT code 52282 for cystoscopy with
implant of a stent and a Level II HCPCS C code for a stent, to CY 2006
claims that include CPT code 52282 but do not include a device C-code
for a stent. While a stent is always necessary for the procedure and we
require that hospitals report device HCPCS codes whenever they implant
a device that is described by an available device code, we found that
hospitals did not always report a stent HCPCS code with CPT code 52282.
This is similar to our findings in other cases of device-related
procedures. We believe, however, that hospitals are usually otherwise
accounting for the device cost in their charges on claims for CPT code
52282, either by incorporating the charge into the charge for the
procedure or reporting a charge on an uncoded revenue code line. We
found only a small difference in median costs of approximately $500 for
procedures reported with and without a device C-code. This difference
in costs is well within an appropriate range for the APC group.
Furthermore, the median cost for the claims billed with CPT code 52282
and a stent C-code was approximately $2,369, very close to the CY 2008
median cost of APC 0163 of approximately $2,270. We also believe that
CPT code 52282 clinically resembles the other cystourethroscopic
procedures also assigned to APC 0163. Therefore, we do not believe that
there are sufficient differences in clinical characteristics or
resources required to perform the procedure described by CPT code 52282
relative to the other procedures assigned to APC 0163 to warrant
reassignment of CPT code 52282 to a new, device-dependent APC as the
commenter suggested.
After consideration of the public comment received, we are
finalizing our proposal, without modification, to assign CPT code 52282
to APC 0163, with a CY 2008 median cost of approximately $2,270.
b. Percutaneous Renal Cryoablation (APC 0423)
For CY 2008, we proposed to assign CPT code 0135T (Ablation renal
tumor(s), unilateral, percutaneous, cryotherapy) to APC 0423 (Level II
Percutaneous Abdominal and Biliary Procedures), with a proposed payment
rate of approximately $2,810. This code was new in CY 2006, when it was
assigned to APC 0163 (Level IV Cystourethroscopy and other
Genitourinary Procedures) on an interim final basis, with a payment
rate of $1,999. In CY 2007, based on the APC Panel's recommendation
made at the March 2006 APC Panel meeting, we reassigned CPT code 0135T
from APC 0163 to APC 0423 with a payment rate of approximately $2,297.
We expected hospitals, when billing CPT code 0135T, to also report the
device HCPCS code, C2618 (Probe, cryoablation), associated with the
procedure.
We received several public comments concerning this proposal. A
summary of the public comments and our responses follow.
Comment: Several commenters disagreed with our proposed APC
assignment for CPT code 0135T. They indicated that the proposed payment
rate for APC 0423 does not cover the cost hospitals incur for the
cryoprobes used in the procedure. One commenter reported that the
average cost of one probe is about $1,000, while several commenters
indicated that a single procedure, on the average, uses about 2.5
probes but may involve up to 4 probes depending on the size of the
tumor and the probe needle selected. Other commenters argued that CPT
code 0135T requires more resources than the other procedures currently
assigned to APC 0423, specifically CPT codes 47382 (Ablation, one or
more liver tumor(s), percutaneous, radiofrequency) and 50592 (Ablation,
one or more renal tumor(s), percutaneous, unilateral, radiofrequency).
Several commenters highlighted the variance in the use of probes used
for the procedures assigned to APC 0423. Specifically, these commenters
asserted that CPT code 0135T requires the use of multiple probes while
the radiofrequency ablation procedures require only a single probe in a
procedure. Further, the commenters highlighted the various median costs
associated with the procedures assigned to APC 0423. That is, they
pointed out that the proposed median cost of about $3,520 for CPT code
0135T was 30 to 32 percent more than the median cost for CPT code
47382, which had a proposed median cost of about $2,706, or CPT code
50592, which had a proposed median cost of about $2,658. The commenters
urged CMS to reevaluate the proposed payment rate for APC 0423 and use
acquisition cost data provided by manufacturers, as many of the claims
used to set the payment rate do not contain the required device.
Alternatively, some commenters requested that CMS consider creating a
unique clinical APC for renal cryoablation that would be designated as
device-dependent to appropriately distinguish the resource costs
associated with renal cryoablation from radiofrequency ablation
procedures.
Response: Based on our comprehensive review of the procedures
assigned to APC 0423, public comments, and the CY 2006 recommendation
of the APC Panel regarding renal cryoablation, we believe that we have
appropriately assigned CPT code 0135T to APC 0423 for CY 2008 based on
clinical and resource considerations. We disagree with the commenters'
argument regarding the clinical dissimilarity of the renal cryoablation
procedure from the radiofrequency ablation procedures in APC 0423. The
commenters to the CY 2007 OPPS proposed rule (71 FR 68049) acknowledged
that cryoablation and radiofrequency percutaneous ablation procedures
for renal tumors are clinically similar. We continue to believe that
CPT code 0135T is appropriately assigned to APC 0423 because it is
placed with other procedures that share its clinical and resource
characteristics. 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 cryoablation probes used to
perform CPT code 0135T as the units of HCPCS code C2618 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 informed us that the hospital claims
data that we used to set the proposed payment rate for CPT code 0135T
do not accurately capture the full costs related to this procedure.
They believed that the omission on the claims for the device C-code,
specifically HCPCS code C2618,
[[Page 66709]]
for the cryoprobes leads to omission of cryoprobe cost information and
undervaluation of the cost of the procedure. Some commenters reported
the results of their study of our hospital outpatient claims data which
revealed that of the 110 Medicare claims submitted for CPT code 0135T,
only 44 single claims included the device HCPCS C-code (C2618) on the
claims. Because the procedure cannot be performed without the cryoprobe
device, these commenters strongly urged CMS to designate the renal
cryoablation procedure as a ``device-dependent'' procedure and require
hospitals to submit claims with the appropriate HCPCS C-code. One
commenter who acknowledged its experience with hospital billing
reported that hospitals are not motivated to report the cost of the
devices on the claim form unless a HCPCS C-code is required by a code
edit for claim submission. Several commenters requested that CMS
designate CPT code 0135T as a ``device-dependent'' procedure to ensure
that future claims data more accurately reflect the total cost of the
procedure.
Response: We acknowledge the concerns raised by the commenters
regarding the hospitals' failure to report the device HCPCS code C2618
with the procedure. We further examined our CY 2006 hospital outpatient
claims data to determine the frequency of billing CPT code 0135T with
and without HCPCS code C2618. Our analysis revealed that the final rule
median cost of approximately $3,446 based on 48 single bills used for
ratesetting falls within the range for those procedures billed with and
without the device HCPCS code C2618. Specifically, our data showed a
median cost of about $4,402 based on 17 single bills for procedures
billed with the device HCPCS code C2618 and a median cost of about
$2,834 based on 31 single bills for those procedures billed without the
device C-code. Even considering only those claims for CPT code 0135T
with the device HCPCS code and higher median cost, CPT code 0135T would
be appropriately assigned to APC 0423 based on that cost.
Further, we do not believe that we should create a claims
processing edit in this instance. We create device edits, when
appropriate, for procedures assigned to device-dependent APCs, where
those APCs have been historically identified under the OPPS as having
very high device costs. Because APC 0423 is not a device-dependent APC
and the costs of the procedure with and without HCPCS code C2618 are
reasonably similar, we will not create edits. We remind hospitals that
they must report all of the HCPCS codes that appropriately describe the
items used to provide services, regardless of whether the HCPCS codes
are packaged or paid separately.
After further analysis of our CY 2006 hospital outpatient claims
data, the APC Panel recommendation from the March 2006 meeting, and
consideration of the public comments received, we are finalizing our
proposal, without modification, to assign CPT code 0135T to APC 0423
for CY 2008 with a median cost of approximately $2,705.
For CY 2008, the CPT Editorial Panel decided to delete CPT code
0135T on December 31, 2007, and replace it with CPT code 50593
(Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy). The
replacement CPT code 50593 will be assigned to APC 0423 effective
January 1, 2008. Similar to its predecessor code, we expect hospitals
to report both the device HCPCS code C2618 and CPT code 50593 to
appropriately report the renal cryoablation procedure.
c. Prostatic Thermotherapy (APC 0163)
For CY 2008, we proposed to reconfigure certain clinical APCs to
eliminate most of the low total volume APCs as an alternative to
developing specific quantitative approaches to treating low total
volume APCs differently for purposes of median calculation. We further
concluded that there were other clinical APCs with higher volumes of
total claims to which these low total volume services could be
reassigned, while maintaining the continued clinical and resource
homogeneity of the clinical APCs to which they would be newly
reassigned. As a result, we eliminated certain APCs and reassigned the
procedures associated with these APCs to other clinical APCs with
higher volumes of claims. Prostatic thermotherapy procedures were
assigned to APC 0675 (Prostatic Thermotherapy) for CY 2007, with a
payment rate of approximately $2,529. For CY 2008, we proposed to
reassign CPT codes 53850 (Transurethral destruction of prostate tissue;
by microwave thermotherapy) and 53852 (Transurethral destruction of
prostate tissue; by radiofrequency thermotherapy) from APC 0675 to APC
0163 (Level IV Cystourethroscopy and other Genitourinary Procedures),
with a proposed payment rate of approximately $2,351. We proposed to
eliminate APC 0675, which would otherwise have included only
approximately 550 total services based on CY 2006 claims.
We received some public comments on the proposed deletion of APC
0675 and the reassignment of the prostatic thermotherapy procedures in
APC 0675 to APC 0163. A summary of the public comments and our response
follow.
Comment: Specifically, some commenters requested clarification from
CMS on the reassignment of CPT codes 53850 and 53852 from APC 0675 to
APC 0163, as reflected in Addendum B of the CY 2008 OPPS proposed rule.
One commenter urged CMS to investigate whether these procedures were
correctly assigned to APC 0163 as the procedures described by CPT codes
53850 and 53852 seemed more appropriate, in terms of clinical
characteristics and resource costs, for assignment to APC 0429 (Level V
Cystourethroscopy and other Genitourinary Procedures). The commenter
recommended that the APC Panel discuss this issue at its next meeting
to further review the data before the proposed change is finalized.
Response: As part of our annual review, we examine the APC
assignments for all items and services under the OPPS for appropriate
placements in the context of our proposed policies for the update year.
This review involves careful and extensive analysis of our hospital
outpatient claims data, as well as input from our medical advisors and
the APC Panel and recommendations from the public. Based on our
analysis of the hospital outpatient claims from CY 2006, the final
median cost for CPT code 53850 is approximately $2,482 based on 199
single claims (223 total), and the final median cost for CPT code 53852
is approximately $2,894 based on 195 single claims (315 total). We
agree with the commenter who recommended reassignment of these CPT
codes to APC 0429, which has a median cost of approximately $2,844 for
CY 2008 and includes several other procedures to destroy prostate
tissue. We believe that APC 0429 is the most appropriate assignment for
both CPT codes based on clinical and resource considerations.
After consideration of the public comments received, we are
modifying our proposal and finalizing the CY 2008 assignments of CPT
codes 53850 and 53852 to APC 0429, with a median cost of approximately
$2,844.
d. Radiofrequency Ablation of Prostate (APC 0163)
For CY 2008, we proposed to delete APC 0675 (Prostatic
Thermotherapy) and reassign the two CPT codes that mapped to this APC
in CY 2007, CPT code 53850 (Transurethral destruction of prostate
tissue; by microwave thermotherapy) and CPT code 53852
[[Page 66710]]
(Transurethral destruction of prostate tissue; by radiofrequency
thermotherapy) to APC 0163 (Level IV Cystourethroscopy and other
Genitourinary Procedures). The CY 2007 payment rate for APC 0675 is
approximately $2,529, and the CY 2008 proposed payment rate for APC
0163 was approximately $2,351.
Comment: One commenter asserted that the proposed reassignment of
CPT code 53852 to APC 0163 is not clinically appropriate or consistent
with the resource costs of other procedures assigned to APC 0163. The
commenter suggested that CMS reassign CPT code 53852 to APC 0429 (Level
V Cystourethroscopy and other Genitourinary Procedures), with a CY 2008
proposed payment rate of approximately $2,924. According to the
commenter, CMS cost data showed that the median cost of CPT code 53852
is 26 percent higher than the median cost of the APC 0163 to which CMS
proposed to reassign the procedure. The commenter stated that the
clinical characteristics of the procedure described by CPT code 53852
are more similar to the procedure described by CPT code 52647 (Laser
coagulation of the prostate, including control of postoperative
bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral
calibration and/or dilation, and internal urethrotomy are included if
performed)), which maps to APC 0429, than the procedures that are
included in APC 0163. Specifically, the commenter stated that both
procedures can be done under direct visualization, placement of the
energies are customized, and there is no incision or cutting of the
tissues involved. The commenter also argued that CMS data on
intraservice procedure times and the direct costs of clinical labor,
supplies, and equipment indicate that CPT code 53852 should be
reassigned to APC 0429 rather than to APC 0163.
Response: We examined the clinical characteristics and claims-based
resource costs of all procedures proposed for assignment to APC 0163
and APC 0429 for CY 2008. We agree with the commenter that APC 0429
would be an appropriate assignment for CPT code 53852 for CY 2008. CPT
code 53852 appears to be more closely related, both in terms of
clinical characteristics and resource costs, to the laser surgery
procedures assigned to APC 0429 than to many of the cystourethroscopy
and transurethral resection procedures assigned to APC 0163. CPT code
53852, like some other procedures assigned to APC 0429, is a minimally
invasive procedure for the destruction of prostate tissue, and we
believe the procedure room time and recovery period for the services
would be relatively comparable.
After consideration of the public comments received, we are
modifying our CY 2008 proposal and will reassign CPT code 53852 to APC
0429, with a median cost of approximately $2,844.
e. Ultrasound Ablation of Uterine Fibroids With Magnetic Resonance
Guidance (MRgFUS) (APC 0067)
Magnetic resonance guided focused ultrasound (MRgFUS) is a
noninvasive surgical procedure that uses high intensity focused
ultrasound waves to destroy tissue in combination with magnetic
resonance imaging (MRI) guidance. Currently, the two Category III CPT
codes for this procedure are 0071T (Focused ultrasound ablation of
uterine leiomyomata, including MR guidance; total leiomyomata volume
less than 200 cc of tissue) and 0072T (Focused ultrasound ablation of
uterine leiomyomata, including MR guidance; total leiomyomata volume
greater or equal to 200 cc of tissue), which were implemented on
January 1, 2005.
In the CY 2006 OPPS proposed rule, we proposed to continue to
assign both codes to APC 0193 (Level V Female Reproductive Proc).
However, at the August 2005 APC Panel meeting, the APC Panel
recommended that CMS work with stakeholders to assign CPT codes 0071T
and 0072T to appropriate New Technology APCs. Based on our review of
several factors, which included information presented at the August
2005 APC Panel meeting, the public comments received on the CY 2006
OPPS proposed rule, and our analysis of OPPS claims data for different
procedures, we reassigned CPT code 0071T from APC 0193 to APC 0195
(Level IX Female Reproductive Proc) and CPT code 0072T from APC 0193 to
APC 0202 (Level X Female Reproductive Proc) effective January 1, 2006,
to reflect the higher level of resources we estimated were required
when performing the MRgFUS procedures.
In the CY 2007 OPPS/ASC proposed rule, we proposed to continue to
assign CPT code 0071T to APC 0195 and CPT code 0072T to APC 0202. We
received comments on the CY 2007 proposed APC assignments recommending
that we revise the APC assignments for CPT codes 0071T and 0072T. The
commenters indicated that, while MRgFUS treats anatomical sites that
are similar to other procedures assigned to APCs 0195 and 0202, the
resources utilized differed dramatically. Several commenters
recommended that the most appropriate APC 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.
As we stated in both the CY 2006 OPPS final rule with comment
period and the CY 2007 OPPS/ASC final rule with comment period, we
believe that MRgFUS treatment bears a significant relationship to
technologies already in use in HOPDs (70 FR 68600 and 71 FR 68050,
respectively). 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
continue to believe that, although MRgFUS therapy is relatively new, it
is an integrated application of existing technologies (MRI and
ultrasound), and its technology resembles other OPPS services that are
assigned to clinical APCs for which we have significant OPPS claims
data. In the CY 2007 OPPS/ASC final rule with comment period (71 FR
68050), we explained our belief that retaining MRgFUS procedures in
clinical APCs with other female reproductive procedures would enable us
both to set accurate payment rates and to maintain appropriate clinical
homogeneity of the APCs. Furthermore, we did not agree with commenters
that MRgFUS procedures shared sufficient clinical and resource
characteristics with cobalt-based stereotactic radiosurgery (SRS) to
reassign them to that particular clinical APC 0127, where only the
single specific SRS procedure was assigned for CY 2007 and which had a
CY 2007 APC median cost of approximately $8,461. Consequently, in the
CY 2007 OPPS/ASC final rule with comment period (71 FR 68051), we
finalized payment for these procedures in APCs 0195 and 0202 as
proposed.
Analysis of our hospital outpatient data for claims submitted for
CY 2006 during the development of the proposed rule indicated that
MRgFUS procedures were rarely performed on Medicare patients. As we
stated in the CY 2006 OPPS final rule with comment period and the CY
2007 OPPS/ASC final rule with comment period, because treatment of
uterine fibroids is most common among women younger than 65 years of
age, we did not expect that there ever would be many Medicare claims
for the MRgFUS procedures (70 FR 68600 and 71 FR 68050, respectively).
For OPPS claims submitted from CY 2005 through CY 2006, our claims data
showed that there
[[Page 66711]]
were only two claims submitted for CPT code 0071T in CY 2005 and one in
CY 2006. We had no hospital claims for CPT code 0072T from either of
those years.
At its March 2007 meeting, the APC Panel recommended that, for CY
2008, CMS reassign CPT codes 0071T and 0072T from APCs 0195 and 0202 to
APC 0067 (Level III Stereotactic Radiosurgery, MRgFUS, and MEG), which
had a proposed APC median cost of approximately $3,870 for CY 2008. The
APC Panel discussed its general belief that while the MRgFUS procedures
might not be performed frequently on Medicare patients, CMS should pay
appropriately for the procedures to ensure access for Medicare
beneficiaries. In addition, following discussion of the potential for
reassignment of the CPT codes to New Technology APCs, the APC Panel
specifically recommended that the procedures be assigned to a clinical
APC at this point in their adoption into clinical practice, instead of
a New Technology APC. Furthermore, following publication of the CY 2007
OPPS/ASC final rule with comment period, we received input from
interested individuals and organizations regarding the clinical and
resource characteristics of MRgFUS procedures. Based on our
consideration of all information available to us regarding the
necessary hospital resources for the MRgFUS procedures in comparison
with other procedures for which we have historical hospital claims
data, for CY 2008 we proposed to accept the APC Panel's recommendation
to reassign these services to clinical APC 0067, an APC that currently
contains two linear accelerator-based stereotactic radiosurgery (SRS)
procedures. We agreed with the APC Panel that these SRS procedures
share sufficient clinical and resource similarity with the MRgFUS
services, including reliance on image guidance in a single treatment
session to ablate abnormal tissue, to justify their assignment to the
same clinical APC. Unlike the cobalt-based SRS service that we
concluded in the CY 2007 OPPS/ASC final rule with comment period was
not similar to MRgFUS procedures based on clinical and resource
considerations, these linear accelerator-based SRS procedures are not
performed solely on intracranial lesions and generally do not require
immobilization of the patient's head in a frame that is screwed into
the skull, thereby exhibiting characteristics more consistent with
MRgFUS treatments. In addition, based on our understanding of the
MRgFUS procedures described by the two CPT codes which differ only in
the volume of uterine leiomyomata treated, we believed it would be most
appropriate to assign both of these procedures to the same clinical
APC, as recommended by the APC Panel. Therefore, for CY 2008 we
proposed to reassign CPT codes 0071T and 0072T to APC 0067, with a
proposed APC median cost of approximately $3,870, which was reflected
in Table 32 of the proposed rule (72 FR 42713).
We received several public comments on our CY 2008 proposal
concerning MRgFUS procedures. A summary of the public comments and our
responses follow.
Comment: Several commenters agreed with CMS's proposal to assign
the MRgFUS procedures, specifically CPT codes 0071T and 0072T, to APC
0067 because the services share similarities, both clinically and with
regard to resource costs, with other procedures also assigned to APC
0067. However, many commenters disagreed with the proposed payment rate
of approximately $3,918 for APC 0067. They recommended that MRgFUS be
placed in APC 0127 (Level IV Stereotactic Radiosurgery, MRgFUS, and
MEG), which had a proposed payment rate of approximately $7,864, as
they believed that this APC accurately reflected the hospital charges
and costs for this procedure. The commenters believed that the proposed
payment rate for APC 0067 was far below the costs incurred to provide
MRgFUS procedures and did not accurately reflect the treatment planning
component that is part of the MRgFUS procedure. Other commenters
disagreed with the placement of MRgFUS services in an APC that
historically had contained only SRS procedures. These same commenters
argued that the MRgFUS procedure is not similar to SRS treatment
delivery services based on clinical coherence and resource utilization.
Some commenters suggested that CMS reassign these procedures, as
previously done in CY 2007, to a female reproductive procedure APC.
Response: As we stated in the CY 2006 OPPS final rule with comment
period and the CY 2007 OPPS/ASC final rule with comment period, because
treatment of uterine fibroids is most common among women younger than
65 years of age, we did not expect that there ever would be many
Medicare claims for the MRgFUS procedures (70 FR 68600 and 71 FR 68050,
respectively). Analysis of hospital outpatient data for claims
submitted for CY 2006 indicates that MRgFUS procedures were rarely
performed on Medicare patients. For OPPS claims submitted from CY 2005
through CY 2006, our claims data showed that there were only two claims
submitted for CPT code 0071T in CY 2005 and one in CY 2006. We had no
hospital claims for CPT code 0072T from either of those years. While we
have no information from hospital claims regarding the costs of MRgFUS
procedures, we continue to believe that the clinical and expected
resource characteristics of MRgFUS procedures resemble the first or
complete session LINAC-based SRS treatment delivery services that are
also assigned to APC 0067. The APC Panel also recommended that MRgFUS
procedures be assigned to that clinical APC, instead of a New
Technology APC. While commenters pointed to specific differences in the
technologies utilized for MRgFUS and SRS procedures, both services are
noninvasive and utilize specialized equipment and image guidance in the
targeted ablation of abnormal tissue during a lengthy treatment
session. Therefore, we believe that the services are sufficiently
similar to reside in the same clinical APC.
After consideration of the public comments received and the APC
Panel recommendation at its March 2007 meeting, we are finalizing our
proposal, without modification, to assign CPT codes 0071T and 0072T to
APC 0067, with a CY 2008 median cost of approximately $3,882. Table 18
lists the final APC median costs for the MRgFUS CPT codes.
Table 18.--Final CY 2008 APC Assignments of MRgFUS Procedures
----------------------------------------------------------------------------------------------------------------
Final CY
HCPCS code Short descriptor CY 2007 SI CY 2007 CY 2007 APC Final CY 2008 Final CY 2008 APC
APC median cost SI 2008 APC median cost
----------------------------------------------------------------------------------------------------------------
0071T.......... U/s leiomyomata T......... 0195 $1,742 S............. 0067 $3,882
ablate <200.
0072T.......... U/s leiomyomata T......... 0202 $2,534 S............. 0067 $3,882
ablate >200.
----------------------------------------------------------------------------------------------------------------
[[Page 66712]]
f. Uterine Fibroid Embolization (APC 0202)
Prior to January 1, 2007, a specific CPT code did not exist to
describe uterine fibroid embolization. CPT guidance suggests that
hospitals previously reported this procedure using CPT codes 37204
(Transcatheter occlusion or embolization (eg, for tumor destruction, to
achieve hemostasis, to occlude a vascular malformation), percutaneous,
any method, non-central nervous system, non-head or neck) and 75894
(Transcatheter therapy, embolization, any method, radiological
supervision and interpretation). In CY 2006, the combined APC payment
for these two procedures was approximately $2,504. Effective January 1,
2007, the CPT Editorial Panel created CPT code 37210 (Uterine fibroid
embolization (UFE, embolization of the uterine arteries to treat
uterine fibroids, leiomyomata), percutaneous approach inclusive of
vascular access, vessel selection, embolization, and all radiological
supervision and interpretation, intraprocedural roadmapping, and image
guidance necessary to complete the procedure) to describe this
procedure. In the CY 2007 OPPS/ASC final rule with comment period (71
FR 68317), we provided an interim final assignment of CPT code 37210 to
APC 0202 (Level VII Female Reproductive Procedures), with a CY 2007
payment rate of approximately $2,642. For CY 2008, we proposed
continued assignment of CPT code 37210 to APC 202 (72 FR 42936), with a
proposed payment rate of approximately $2,753. Because this is a new
code for CY 2007, the CY 2006 claims data, upon which we set CY 2008
payment rates, do not reflect use of this code.
At the September 2007 meeting of the APC Panel, the Panel
recommended that CMS consider moving CPT code 37210 to another APC,
such as APC 0067 (Level III Stereotactic Radiosurgery), with a CY 2008
proposed payment rate of approximately $3,918, or APC 0229
(Transcatheter Placement of Intravascular Shunts), with a CY 2008
proposed payment rate of approximately $5,713, to improve the clinical
and resource homogeneity of the procedure within its assigned APC.
We received several public comments on the CY 2007 OPPS/ASC final
rule with comment period and the CY 2008 OPPS/ASC proposed rule
regarding the placement of CPT code 37210 in APC 0202. A summary of the
public comments and our response follow.
Comment: Several commenters requested that CMS consider the APC
Panel's recommendation to reassign CPT code 37210 to a different APC.
The commenters argued that the uterine fibroid embolization procedure
is clinically dissimilar to the other procedures assigned to APC 0202,
which do not require the implantation of a device and do not utilize
imaging resources. The commenters suggested that CMS create a new APC
for CPT code 37210 or reassign it to APC 0229. The commenters stated
that the uterine fibroid embolization procedure is similar to the other
vascular procedures included in APC 0229, both clinically and in terms
of resource utilization. Specifically, the commenters noted that the
uterine fibroid embolization procedure is similar to the revision of
transvenous intrahepatic portosystemic shunts, described by CPT code
37183 (Revision of transvenous intrahepatic portosystemic shunt(s)
(TIPS) (includes venous access, hepatic and portal vein
catheterization, portography with hemodynamic evaluation, intrahepatic
tract recanulization/dilatation, stent placement and all associated
imaging guidance and documentation)), which maps to APC 0229. According
to the commenters, both uterine fibroid embolization and the revision
of transvenous intrahepatic portosystemic shunts involve device
implantation, selective catheterization, and radiological supervision
and interpretation. The commenters stated that the hospital resource
consumption related to the devices used in uterine fibroid embolization
are also similar to other procedures in APC 0229, including those
described by CPT code 37205 (Transcatheter placement of an
intravascular stent(s) (except coronary, carotid, and vertebral
vessel), percutaneous; initial vessel) and CPT code 37206
(Transcatheter placement of an intravascular stent(s) (except coronary,
carotid, and vertebral vessel), percutaneous; each additional vessel).
Response: We reviewed the clinical characteristics and claims-based
costs of all procedures also proposed for assignment to APC 0202 for CY
2008, as well as the recommendation of the APC Panel from its September
2007 meeting. We do not believe that the procedure described by CPT
code 37210 sufficiently resembles the services assigned to APC 0067,
one of the possibilities recommended by the APC Panel, for that
clinical APC to be an appropriate assignment. The stereotactic
radiosurgery, magnetic resonance-guided focused ultrasound ablation,
and magnetoencephalography services assigned to APC 0067 all are
noninvasive procedures that do not require vascular catheterization or
the use of implantable devices. We examined the clinical
characteristics and resource costs of procedures assigned to APC 0229
and agree with some of the commenters that this APC would be an
appropriate assignment for CPT code 37210 for CY 2008 while we await
claims data that will be available for the CY 2009 OPPS update. CPT
code 37210, like other procedures assigned to APC 0229, requires the
targeted use of intravascular catheters, imaging guidance, and
implantable devices, and we believe the procedure room time and
recovery period for the services would be relatively comparable. CPT
code 37210 appears to be more closely related, both in terms of
clinical characteristics and resource costs, to the minimally invasive
interventional procedures assigned to APC 0229 than to many of the open
surgical repair procedures of the female reproductive system assigned
to APC 0202. We are unable to assign CPT code 37210 to a new clinical
APC for CY 2008 because we would have no claims data for the procedure
upon which to base the payment rate for that APC. Therefore, we have
adopted the recommendation of the APC Panel to consider moving CPT code
37210 to APC 0229 and will reassign the procedure to that APC for CY
2008.
After consideration of the public comments received, we are
modifying our CY 2008 proposal and will reassign CPT code 37210 for
uterine fibroid embolization to APC 0229, with a median cost of
approximately $5,570.
4. Nervous System Procedures
a. Chemodenervation (APC 0206)
For CY 2008, we proposed to reassign two chemodenervation
procedures, specifically those described by CPT codes 64650
(Chemodenervation of eccrine glands; both axillae) and 64653
(Chemodenervation of eccrine glands; other area(s) (eg, scalp, face,
neck), per day) to APC 0206 (Level II Nerve Injections), with a
proposed payment rate of approximately $265. These services are
currently assigned to APC 0204 (Level I Nerve Injections) for CY 2007,
with a payment rate of approximately $139.
We received one public comment on our CY 2008 proposed assignment
of chemodenervation procedures to APC 0206. A summary of the public
comment and our response follow.
Comment: One commenter was concerned that CMS proposed to reassign
CPT codes 64650 and 64653 to APC 0206 for CY 2008, but retained other
chemodenervation procedures in
[[Page 66713]]
APC 0204, specifically CPT codes 64612 (Chemodenervation of muscle(s);
muscle(s) innervated by facial nerve (eg, for blepharospasm, hemifacial
spasm); 64613 (Chemodenervation of muscle(s); cervical spinal muscle(s)
(eg, for spasmodic torticollis); and 64614 (Chemodenervation of
muscle(s); extremity(s) and/or trunk muscle(s) (eg, for dystonia,
cerebral palsy, multiple sclerosis). The commenter believed that CPT
codes 64650 and 64653 for chemodenervation of eccrine glands should be
grouped with the other three cited chemodenervation codes based on
clinical and resource considerations. Of note, many commenters stated
that if CMS proceeded with the packaging of electrodiagnostic guidance
for chemodenervation procedures, a new distinct APC should be
established for CPT codes 64612, 64613, and 64614, but CPT codes 64650
and 64653 were not included in that request.
Response: CPT codes 64650 and 64653 were new codes in CY 2006,
which were initially assigned to APC 0204 on an interim final basis,
and subsequently retained in that APC for CY 2007. For CY 2008, we
proposed to reassign them to APC 0206 based on analysis of our first
limited claims data from CY 2006. The final rule median cost for APC
0204 is approximately $146 and for APC 0206 is approximately $258. Our
claims data showed a median cost of approximately $221 for CPT code
64650 and a median cost of approximately $235 for CPT code 64653 based
on only 7 claims (of 11 total claims) and 15 claims (of 22 total
claims), respectively. We agree with the commenter that these two
chemodenervation procedures are clinically similar to the three
procedures reported for chemodenervation of the muscles. Given the
final CY 2008 packaging policy as discussed section II.A.4.c.(1) of
this final rule with comment period that will package payment for the
electrodiagnostic guidance for chemodenervation services, we would
expect that the hospital resources required for CPT codes 64612 through
64614, where this guidance is sometimes used, would be at least as
great as those required for chemodenervation of eccrine glands. In view
of the limited claims for CY 2006 for CPT codes 64650 and 64653, we
agree with the commenters that these two CPT codes should be assigned
to the same APC as the other three chemodenervation procedures,
specifically CPT codes 64612 through 64614, whose median costs of
approximately $125 through $187 are within the range of costs for other
significant services also assigned to APC 0204, where these muscle
chemodenervation procedures were proposed for assignment in CY 2008. We
do not see any need to establish a new APC for CPT codes 64612 through
64614 for CY 2008 based on clinical and resource considerations.
Therefore, we believe that CPT codes 64650 and 65653 should remain in
APC 0204 for CY 2008. As we accumulate additional claims data for these
procedures we will reassess their resource utilization and APC
placement.
After consideration of the public comment received, we are
modifying the CY 2008 proposed assignments of CPT codes 64650 and 64653
and retaining these two CPT codes in APC 0204, with a median cost of
approximately $146, rather than reassigning them to APC 0206 as
proposed.
b. Implantation of Intrathecal or Epidural Catheter (APC 0224)
For CY 2008, we proposed to delete APC 0223 (Implantation or
Revision of Pain Management Catheter) and reassign CPT code 62350
(Implantation, revision, or repositioning of tunneled intrathecal or
epidural catheter, for long-term medication administration via an
external pump or implantable reservoir/infusion pump; without
laminectomy) to APC 0224 (Implantation of catheter/reservoir/shunt).
The procedure described by CPT code 62350 is the only procedure
assigned to APC 0223 in CY 2007, with a payment rate of approximately
$1,896. The CY 2008 proposed payment for APC 0224 was approximately
$2,364.
We received one public comment on our CY 2008 proposal to reassign
CPT code 62350 to APC 0224. A summary of the public comment and our
response follow.
Comment: One commenter supported the proposal to delete APC 0223
and reassign CPT code 62350 to APC 0224. According to the commenter,
this policy would increase resource homogeneity and clinical coherence.
Response: We appreciate the commenter's support and agree that the
deletion of APC 0223 and the reassignment of CPT code 62350 to APC 0224
would increase resource homogeneity and clinical coherence of the
resulting APC configuration by assigning multiple similar procedures
for the implantation of nervous system shunts and catheters to the same
clinical APC. We also believe this proposal is consistent with our
overall strategy to encourage hospitals to use resources more
efficiently by increasing the size of the payment bundles, and by
eliminating, whenever possible, APCs comprised of few procedures.
Therefore, we are finalizing our proposal, without modification, to
delete APC 0223 and reassign CPT code 62350 to APC 0224, with a median
cost of approximately $2,282.
c. Implantation of Spinal Neurostimulators (APC 0222)
The CPT code for insertion of a spinal neurostimulator (63685,
Insertion or replacement of spinal neurostimulator pulse generator or
receiver, direct or inductive coupling), which is currently assigned to
APC 0222 (Implantation of Neurological Device), is reported for both
the insertion of a nonrechargeable neurostimulator and a rechargeable
neurostimulator. The costs of a nonrechargeable neurostimulator from
the CY 2005 claims are packaged into the payment for APC 0222 in CY
2007. We believe rechargeable neurostimulators are currently most
commonly implanted for spinal neurostimulation, consistent with the
information provided during our consideration of the device for pass-
through designation. However, in response to hospital requests, in CY
2007 we expanded our procedure-to-device edits to allow device category
code C1820 (Generator, neurostimulator (implantable), with rechargeable
battery and charging system) to be reported with two other procedures.
These procedures are CPT code 64590 (Insertion or replacement of
peripheral or gastric neurostimulator pulse generator or receiver,
direct or inductive coupling), assigned to APC 0222, and CPT code 61885
(Insertion or replacement of cranial neurostimulator pulse generator or
receiver, direct or inductive coupling; with connection to a single
electrode array), assigned to APC 0039 (Level I Implantation of
Neurostimulator).
The rechargeable neurostimulator reported as device category code
C1820 has received pass-through payment since January 1, 2006, and its
pass-through status will expire on January 1, 2008, as discussed
further in section IV.B. of this final rule with comment period. During
the 2 years of pass-through payment when device category code C1820 has
been paid at a hospital's charges reduced to cost using the overall
hospital CCR, we have applied a device offset when device category code
C1820 is reported with a CPT code assigned to APCs 0039 or 0222 in
order to remove the costs of the predecessor nonrechargeable device
from the payment for APCs 0039 and 0222. This device offset ensures
that no duplicate
[[Page 66714]]
device payment is made. As a general policy, under the OPPS we package
payment for the costs of devices into the payment for the procedure in
which they are used.
Because we traditionally have paid for a service package under the
OPPS as represented by a HCPCS code for the major procedure that is
assigned to an APC group for payment, we assess the applicability of
the 2 times rule to services at the HCPCS code level, not at a more
specific level based on the individual devices that may be utilized in
a service reported with a single HCPCS code. If the use of a very
expensive device in a clinical scenario causes a specific procedure to
be much more expensive for the hospital than the APC payment, we
consider such a case to be the natural consequence of a prospective
payment system that anticipates that some cases will be more costly and
others less costly than the procedure payment. In addition, very high
cost cases could be eligible for outlier payment. As we note in section
II.A.4. of this final rule with comment period, decisions about
packaging and bundling payment involve a balance between ensuring some
separate payment for individual services and establishing incentives
for efficiency through larger units of payment. In the case of
implantable nonpass-through devices, these devices are part of the OPPS
payment package for the procedures in which they are used.
Stakeholders encouraged us to deem as two distinct procedures
neurostimulator implantation involving rechargeable and nonrechargeable
devices, so in the CY 2008 proposed rule we conducted a review of our
CY 2006 claims data for APC 0222. This examination showed that the
median costs of the associated neurostimulator implantation procedures
are higher for rechargeable neurostimulator implantation than for
nonrechargeable neurostimulator implantation, as shown in Table 35 of
the proposed rule (72 FR 42716). However, the difference in costs
(approximately $6,500 based on proposed rule data) was not so great
that retaining the procedures for the implantation of both types of
devices for spinal or peripheral neurostimulation in APC 0222 would
cause a 2 times violation, even if we were to consider them to be
distinct procedures. The data did not justify creating a new clinical
APC. In addition, to pay differentially would require us to establish
one or more Level II HCPCS codes for reporting under the OPPS, because
the three CPT codes for which device category code C1820 is currently
an allowed device do not differentiate among the device implantation
procedures based on the specific device used. The creation of special
Level II HCPCS codes for OPPS reporting is generally undesirable,
unless absolutely essential, because it increases hospital
administrative burden as the codes may not be accepted by other payers.
Establishing separate coding and payment would reduce the size of the
APC payment groups in a year in which we proposed to increase packaging
under the OPPS through expanded payment groups.
Therefore, for CY 2008 we proposed to package the costs of
rechargeable neurostimulators into the payment for the CPT codes that
describe the services furnished. Our proposed median cost for APC 0222
was approximately $12,162. We thought this approach to be the most
administratively simple, consistent with the OPPS packaging principles,
and supportive of encouraging hospital efficiency, while also providing
appropriate packaged payment for implantable neurostimulators. In the
proposed rule (72 FR 42716), we specifically requested that commenters
submit comments that address how this specific device implantation
situation differed from many other scenarios under the OPPS, where
relatively general HCPCS codes describe procedures that may utilize a
variety of devices with different costs, and payment for those devices
is packaged into the payment for the associated procedures.
We received many public comments in response to this proposal. A
summary of the public comments and our response follow.
Comment: The commenters urged CMS to pay differentially for
rechargeable and nonrechargeable neurostimulators by creating separate
APCs for the implantation procedures. They argued that the 2 times rule
is a sufficient but not necessary condition for splitting APCs, and
they identified other factors apart from the 2 times rule that should
be taken into consideration in determining APC assignments. The
commenters argued that the resources required to implant rechargeable
versus nonrechargeable neurostimulators vary substantially, and that a
combined APC for these procedures would result in a payment that is
inequitable for both technologies and may lead to incentives for
facilities to furnish only the less costly technology, even when the
more expensive technology is clinically indicated for a particular
patient. The commenters stated that the prospect of hospitals limiting
patient access to rechargeable neurostimulators is particularly
troubling because this technology represents a substantial clinical
improvement for select patients and is more cost-effective compared to
nonrechargeable neurostimulators. The commenters argued that paying
more initially for rechargeable neurostimulators would save the
Medicare program and beneficiaries money in the long term, and improve
overall patient care and satisfaction. The commenters also pointed to
provider concentration as an additional factor that should be
considered in APC assignments. In the case of neurostimulators,
commenters provided data that showed only 27 percent of the total
number of hospitals that implant nonrechargeable neurostimulators also
implant rechargeable neurostimulators, and stated that an APC payment
that combines payment for rechargeable and nonrechargeable
neurostimulator implantation procedures may bias the payment system
against those hospitals.
The commenters disagreed with the assertion in the proposed rule
that creating a new APC dedicated solely to rechargeable
neurostimulator implantation procedures would be inconsistent with OPPS
packaging principles. According to the commenters, distinct treatment
of rechargeable and nonrechargeable neurostimulators is not an issue of
packaging, because the technologies are not ancillary services or
products. Instead, the commenters characterized them as alternative
treatments depending on patient needs, and indicated that neither
rechargeable nor nonrechargeable neurostimulators represent
subordinate, supportive, or optional services relative to the other.
The commenters also disagreed that as rechargeable neurostimulators
become the dominant device implanted for neurostimulation, the median
costs of APC 0222 would increase to reflect the costs of the
technology. According to their analysis of claims data, approximately
60 percent of the CY 2006 single procedure claims for APC 0222 were for
implantation of gastric, sacral, or other types of peripheral nerve
neurostimulator devices, all of which utilize and are indicated for
nonrechargeable technologies only. Therefore, the commenters claimed
that the median costs for APC 0222 would continue to be dominated by
nonrechargeable neurostimulator implantation procedures, even as the
utilization of rechargeable neurostimulators grows.
The commenters responded to the proposed rule request to describe
how this specific device implantation situation differed from many
other scenarios under the OPPS, where relatively general HCPCS codes
describe
[[Page 66715]]
procedures that may utilize a variety of devices with different costs,
and payment for those devices is packaged into the payment for the
associated procedures. The commenters stated that they were unaware of
other APCs that include devices where the magnitude of the cost
difference among packaged services is as substantial as proposed for
neurostimulators. They also asserted that, unlike other OPPS services,
rechargeable neurostimulators can reduce long-term costs. Rather than
promoting efficiency, they argued, the CMS proposal to group payment
for rechargeable neurostimulator implantation procedures with
procedures involving nonrechargeable neurostimulators would discourage
efficient resource utilization. They submitted economic models
presented at special society meetings that concluded rechargeable
spinal neurostimulators should reduce the number of reimplantation
procedures due to battery depletion as well as reduce the number of
complications associated with reimplantation procedures, and ultimately
result in cost savings to payers and the health system.
The commenters offered various coding mechanisms that would enable
the creation of unique APCs for rechargeable and nonrechargeable
neurostimulator implantation procedures. Some commenters urged CMS to
create new Level II HCPCS codes to differentiate between
neurostimulator implantation procedures involving nonrechargeable and
rechargeable devices, assign those HCPCS codes to separate APCs, and
discontinue the use of CPT codes describing these procedures for OPPS
payment purposes. These commenters stated that any administrative
burden posed by new Level II HCPCS codes would be outweighed by the
higher payment the hospital would receive for rechargeable
neurostimulators, and that this methodology is consistent with previous
CMS actions to identify and allow specific payment for services of
importance to Medicare. Other commenters, however, supported the CMS
proposal not to implement new Level II HCPCS codes, arguing that it is
too much of an administrative burden for hospitals to follow coding
rules for Medicare patients that are inconsistent with CPT coding
guidelines. They suggested that neurostimulator implantation procedures
that contain the existing C-code for the rechargeable device (C1820)
map to a new APC with a higher payment rate, while claims for
neurostimulator implantation procedures with the existing C-code for
the nonrechargeable device (C1767) continue to map to APC 0222. Other
commenters requested that CMS pursue new CPT codes through the AMA
rather than create new Level II HCPCS codes.
Response: After consideration of the comments received on this
issue, we have decided to reconfigure the APC assignments of procedures
involving implantation of neurostimulators in order to improve the
resource homogeneity of these APCs and ensure appropriate payment for
both rechargeable and nonrechargeable neurostimulators. Effective
January 1, 2008, CMS will implement a revised APC configuration for
neurostimulator implantation procedures that groups payment for certain
procedures mainly involving nonrechargeable neurostimulator technology
(that is, cranial, sacral, gastric, or other peripheral
neurostimulators) into two clinical APCs (APCs 0039 and 0315), while
establishing a single APC for spinal neurostimulator implantation,
which may commonly utilize either rechargeable or nonrechargeable
technologies (APC 0222). Specifically, CMS will reassign CPT code 64590
for implantation of peripheral neurostimulators from APC 0222 to APC
0039, which already includes CPT code 61885 for implantation of single
array cranial neurostimulators. CPT code 63685 for the implantation of
spinal neurostimulators will be the only code remaining in APC 0222. By
moving CPT code 64590 to APC 0039, all procedures that generally use
nonrechargeable technologies only will be removed from ratesetting for
spinal neurostimulator implantation, for which both rechargeable and
nonrechargeable neurostimulators are indicated and commonly utilized.
This APC reconfiguration will not affect CPT code assignment to APC
0315 (Level II Implantation of Neurostimulators), which will continue
to include only CPT code 61886 (Insertion or replacement of cranial
neurostimulator pulse generator or receiver, direct or inductive
coupling; with connection to two or more electrode arrays), although we
will rename all three APCs to accommodate this new configuration. The
revised APC configuration and naming convention for neurostimulator
implantation APCs are summarized in Table 19 below. We note that this
approach does not require hospitals to alter their coding practices in
any way to conform to the new payment policy.
We agree with commenters that there are other important factors we
consider when deciding on APC assignments besides the 2 times rule. In
our CY 2001 final rule, we recognized that resource homogeneity is a
fundamental criterion for evaluating changes to APC assignments. We
wrote in the CY 2001 final rule that ``if the procedures within an APC
require widely varying resources, it would be difficult to develop
equitable payment rates. Aggregated payments to a facility that
performed a disproportionate share of either the expensive or
inexpensive procedures within an APC would be distorted. Further, the
facility might be encouraged to furnish only the less costly procedures
within the APC, resulting in a potential access problem for the more
costly services'' (65 FR 18457). In the case of the neurostimulator
implantation APC configuration that we are adopting for CY 2008, two of
the APCs contain only one procedure and one APC contains only two CPT
codes, with very close CPT code-specific median costs, so these three
APCs reflect great resource homogeneity. We do not consider the
implantation of rechargeable and nonrechargeable neurostimulators to be
different procedures, so we see no need to adopt differential coding
and/or payment for procedures that depend on the device implanted. We
believe our final APC configuration will provide appropriate payment
for neurostimulator implantation procedures that ensures access to the
appropriate neurostimulator technologies under the OPPS for Medicare
beneficiaries.
Just as we do not want to provide incentives for the
underutilization of rechargeable neurostimulators, we also do not want
to provide incentives for the overutilization of this expensive
technology. According to information provided by the manufacturers of
rechargeable neurostimulators, these devices are clinically indicated
in only a subset of patients for whom spinal neurostimulation is a
treatment option. They estimate that approximately 35 percent of these
patients are candidates for rechargeable spinal neurostimulators,
although this proportion may be higher. Our claims data from CY 2006,
the first year of device pass-through for the rechargeable devices,
already indicate that rechargeable neurostimulators are being implanted
in about one-third of the spinal neurostimulator implantation cases. We
received comments from many providers, however, who stated that they
use or wish to use the rechargeable technology in all of their
patients. We believe that creating a separate APC for rechargeable
neurostimulator implantation, as was recommended by commenters, could
[[Page 66716]]
create incentives for hospitals to use the more expensive rechargeable
technology, even when the more expensive technology is not clinically
indicated. In contrast to the commenters' perspective, we believe that
packaging payment for implantable devices into the related procedures
is an important packaging principle that contributes to the size of the
OPPS payment bundles. Although our CY 2008 proposal was to newly
package payment for certain ancillary and supportive services, many
other items and types of services that are fundamental to a procedure's
therapeutic effect have been historically packaged under the payment
system and will remain packaged for CY 2008. A policy to provide
different payments for procedures according to the devices implanted
would not be consistent with our overall strategy to encourage
hospitals to use resources more efficiently by increasing the size of
the payment bundles. However, we believe that the revised
neurostimulator APC configuration that we are adopting for CY 2008 will
allow us to calculate payment rates for procedures involving spinal
neurostimulators that reflect changes in surgical practice based on
clinical, rather than financial, considerations. To the extent that
rechargeable neurostimulators may become the dominant device implanted
for spinal neurostimulation over time based on the evolution of
clinical practice, the median costs for the spinal neurostimulator
implantation APC may increase to reflect contemporary utilization
patterns.
In summary, for CY 2008, we are finalizing our proposal, with
modification, for payment of neurostimulator implantation procedures.
We will implement a revised APC configuration for neurostimulator
implantation procedures that packages payment for procedures involving
mainly nonrechargeable neurostimulator technology (i.e., cranial,
sacral, gastric, or other peripheral neurostimulators) into two APCs
(APCs 0039 and 0315), while establishing a single APC for spinal
neurostimulator implantation, which commonly utilizes either
rechargeable or nonrechargeable technologies (APC 0222). We believe
that this revised APC configuration best serves the principles of a
prospective payment system by following our standard practice of
retaining a single CPT code for neurostimulator implantation procedures
that does not distinguish between the implantation of rechargeable and
nonrechargeable neurostimulators, into which the costs of both types of
devices are packaged in relationship to their OPPS utilization. We also
believe the revised APC configuration is both consistent with our
standard ratesetting practice for technologies coming off pass-through
status, and reflective of the clinical and resource considerations
presented by commenters. Because no new codes or coding practices will
be required, hospitals will not experience any change in the
administrative burden associated with reporting neurostimulator
implantation procedures.
Table 19.--CY 2008 APC Configuration for Payment of Rechargeable and Nonrechargeable Neurostimulator Implantation Procedures
--------------------------------------------------------------------------------------------------------------------------------------------------------
HCPCS codes CY 2008 CY 2008
included in CPT code APC
APC Revised title for CY 2008 Previous title CY 2008 HCPCS descriptor median median
median cost cost cost
--------------------------------------------------------------------------------------------------------------------------------------------------------
0039.............................. Level I Implantation of Level I Implantation of 61885 Insertion or replacement $12,799 $11,732
Neurostimulator. Neurostimulator. of cranial
neurostimulator pulse
generator or receiver,
direct or inductive
coupling; with
connection to a single
electrode array.
64590 Insertion or replacement $10,954 $11,732
of peripheral
neurostimulator pulse
generator or receiver,
direct or inductive
coupling.
0222.............................. Level II Implantation of Implantation of 63685 Insertion or replacement $15,150 $15,150
Neurostimulator. Neurological Device. of spinal
neurostimulator pulse
generation or receiver,
direct or inductive
coupling.
0315.............................. Level III Implantation of Level II Implantation of 61886 Insertion or replacement $16,988 $16,988
Neurostimulator. Neurostimulator. of cranial
neurostimulator pulse
generator or receiver,
direct or inductive
coupling; with
connection to two or
more electrode arrays.
--------------------------------------------------------------------------------------------------------------------------------------------------------
5. Nuclear Medicine and Radiation Oncology Procedures
a. Adrenal Imaging (APC 0391)
For CY 2008, we proposed to assign CPT code 78075 (Adrenal imaging,
cortex and/or medulla) to APC 0391 (Level II Endocrine Imaging), with a
proposed payment rate of about $233. Currently, this procedure is
assigned to the same clinical APC for CY 2007.
We received several public comments concerning this proposal. A
summary of the public comments and our response follow.
Comment: Some commenters requested that CMS recognize this code as
a high intensity multiday imaging procedure and reassign CPT code 78075
to APC 0408 (Level III Tumor/Infection Imaging), along with another
multiday tumor imaging procedure code CPT code 78804
(Radiopharmaceutical localization of tumor or distribution of
radiopharmaceutical agent(s); whole body, requiring two or more days
imaging).
Response: Based on our review of the costs and clinical
characteristics of CPT code 78075, we agree with the commenters that
this procedure is similar to CPT code 78804, in terms of clinical
homogeneity and resource costs. Both procedures require nuclear
medicine imaging several days following the injection of a diagnostic
radiopharmaceutical. We note that these services are nuclear medicine
procedures and, therefore, their final rule median costs are calculated
according to the temporary special methodology that relies on the
subset of claims reporting coded diagnostic radiopharmaceuticals, as
described in section II.A.4.c. of this final rule with comment period.
Our claims data from CY 2006 showed that the median cost for CPT code
78075 is approximately $954 based on 124 single claims for
[[Page 66717]]
ratesetting, which is relatively similar to the median cost of
approximately $1,194 for the sole procedure code 78804 proposed for
assignment to APC 0408. In contrast, the HCPCS-specific median costs
for the individual significant procedures in APC 0391 range from
approximately $201 to $243, resulting in an APC median cost of
approximately $217. The median cost of APC 0391 is significantly lower
than the APC 0408 median cost of approximately $969 and the CPT code
78075 median cost of approximately $954.
After considering the public comments received, we are modifying
our proposal and are reassigning CPT code 78075 to APC 0408, with a CY
2008 median cost of approximately $969, rather than to APC 0391 as
proposed.
b. Injection for Sentinel Node Identification (APC 0389)
For CY 2008, we proposed to assign the sentinel node identification
procedure, specifically described by CPT code 38792 (Injection
procedure; for identification of sentinel node), to APC 0389 (Level I
Non-imaging Nuclear Medicine), with a proposed payment rate of
approximately $101. Currently, this procedure is assigned to the same
clinical APC for CY 2007.
We received several public comments on our CY 2008 proposed
assignment of CPT code 38792 to APC 0389. A summary of the public
comments and our responses follow.
Comment: Some commenters recommended that CPT code 38792 be
reassigned from APC 0389 to APC 0392 (Level II Non-imaging Nuclear
Medicine), which had a proposed payment rate of approximately $209. The
commenters indicated that an injection for sentinel node identification
is more resource intensive, as corroborated by the CMS hospital
outpatient claims data, than other procedures also assigned to APC
0389. These commenters requested that CMS reassign CPT code 38792 to
APC 0392 for CY 2008.
Response: Based on our review of the costs and clinical
characteristics of CPT code 38792, we agree with the commenters that
this procedure is most similar to those procedures assigned to APC 0392
for CY 2008. Our claims data from CY 2006 showed that the median cost
for CPT code 38792 is approximately $174 based on 390 single claims
available for ratesetting, which is significantly higher than the
median cost of approximately $114 for APC 0389. The median cost of APC
0392 of $183, which contains nuclear medicine procedures and,
therefore, is calculated according to the special methodology described
in section II.A.4.c. of this final rule with comment period, is more
consistent with the hospital resources required to perform CPT code
38792.
After consideration of the public comments received, we are
modifying our proposal and reassigning CPT code 38792 to APC 0392, with
a CY 2008 median cost of approximately $183, rather than to APC 0389 as
proposed.
c. Myocardial Positron Emission Tomography (PET) Scans (APC 0307)
From August 2000 to December 31, 2005, under the OPPS, we assigned
one clinical APC to all myocardial positron emission tomography (PET)
scan procedures, which were reported with multiple G-codes through
March 31, 2005. Under the OPPS, effective April 1, 2005, myocardial PET
scans were reported with three CPT codes, specifically CPT codes 78459
(Myocardial imaging, positron emission tomography (PET), metabolic
evaluation), 78491 (Myocardial imaging, positron emission tomography
(PET), perfusion; single study at rest or stress), and 78492
(Myocardial imaging, positron emission tomography (PET), perfusion;
multiple studies at rest and/or stress). From April 1, 2005 through
December 31, 2005, these three CPT codes were assigned to one APC,
specifically APC 0285 (Myocardial Positron Emission Tomography (PET),
with a payment rate of approximately $736. In CY 2006, in response to
the public comments received on the CY 2006 OPPS proposed rule, and
based on our claims information, myocardial PET services were assigned
to two clinical APCs for the CY 2006 OPPS. The CPT codes for the single
scans, specifically 78459 and 78491, were assigned to APC 0306
(Myocardial Positron Emission Tomography (PET) Imaging, Single Study,
Metabolic Evaluation) with a payment rate of approximately $801, and
the multiple scan CPT code 78492 was assigned to APC 0307 (Myocardial
Positron Emission Tomography (PET) Imaging, Multiple Studies) with a
payment rate of approximately $2,485, effective January 1, 2006.
However, analysis of the CY 2005 claims data that were used to set the
payment rates for CY 2007 revealed that when all the myocardial PET
scan procedure codes were combined into a single clinical APC, as they
were prior to CY 2006, the APC median cost for myocardial PET services
was very similar to the median cost of their single CY 2005 clinical
APC. Further, our analysis revealed that the updated differential
median costs of the single and multiple study procedures no longer
supported the two-level APC payment structure. Therefore, for CY 2007,
CPT codes 78459, 78491, and 78492, were assigned to a single clinical
APC, specifically APC 0307, which was renamed ``Myocardial Positron
Emission Tomography (PET) Imaging,'' with a median cost of
approximately $727.
At its March 2007 meeting, the APC Panel recommended that CMS
reassign CPT code 78492 to its own clinical APC, to distinguish this
multiple study procedure that the APC Panel believed would require
greater hospital resources from less resource intensive single study
procedures. However, as indicated in the CY 2008 proposed rule (72 FR
42713), we did not accept the APC Panel's recommendation because,
consistent with our observations from the CY 2005 claims data, our CY
2006 claims data available for the proposed rule did not support the
creation of a clinical APC for CPT code 78492 alone. Analysis of the
latest CY 2006 claims data continued to support a single level APC
payment structure for the myocardial PET scan procedures because very
few single scan studies were performed and we believed single and
multiple scan procedures were clinically similar. Our claims data
available for the proposed rule showed a total of 2,547 procedures
reported with the multiple scan CPT code 78492. Alternatively, our
claims data showed only a combined total of 249 procedures reported
with the single scan CPT codes 78459 and 78491, less than 10 percent of
all studies reported. A similar distribution was observed in the single
bills available for ratesetting.
Similar to findings from the CY 2005 data, as we discussed in the
proposed rule, our CY 2006 claims data revealed that more hospitals
were not only providing multiple myocardial PET scan services, but most
myocardial PET scans were multiple studies. Further, our most recent
data analysis for this final rule with comment period revealed that
multiple myocardial PET scan services were commonly performed in the
same hospital encounter with a cardiovascular stress test, specifically
CPT code 93017 (Cardiovascular stress test using maximal or submaximal
treadmill or bicycle exercise, continuous electrocardiographic
monitoring, and/or pharmacological stress; tracing only, without
interpretation and report).
In the CY 2008 OPPS/ASC proposed rule, we indicated our belief that
the assignment of CPT codes 78459, 78491, and 78492 to a single
clinical APC for CY 2008 was still appropriate because the CY 2006
claims data did not support a resource differential among significant
[[Page 66718]]
myocardial PET services that would necessitate the placement of single
and multiple PET scan procedures into two separate clinical APCs.
Therefore, we proposed to continue to assign both the single and
multiple myocardial PET scan procedure codes to APC 0307, with a
proposed APC median cost of approximately $2,678 for CY 2008. We noted
that the proposed CY 2008 median cost of APC 0307 was significantly
higher than its CY 2007 median cost, in part because of our proposed CY
2008 packaging approach discussed in detail in section II.A.4.c.(5) of
this final rule with comment period that would package payment for
diagnostic radiopharmaceuticals into the payment for their related
diagnostic nuclear medicine studies, such as myocardial PET scans. The
myocardial PET scan CPT codes and their proposed CY 2008 APC
assignments were displayed in Table 33 of the proposed rule, which has
been reproduced as Table 20 below, and updated to show the final status
indicators, APC assignments, and median costs for these services.
We received a number of public comments concerning our proposed
payment for myocardial PET scans. A summary of the public comments and
our response follow.
Comments: Some commenters disagreed with our proposal to assign CPT
codes 78459, 78491, and 78492 to a single clinical APC even though the
CY 2006 claims data did not support a resource differential. They
requested that CMS separate single (rest or stress) from multiple (rest
and stress) PET myocardial perfusion imaging studies. Specifically,
these commenters requested that CMS assign the single myocardial PET
codes, CPT codes 78459 and 78491, to APC 0307, and create a new
clinical APC for CPT code 78492, which describes the multiple
myocardial PET scan procedure. The commenters believed that maintaining
the multiple myocardial PET scan in the same APC as the single
myocardial PET scans significantly underpaid hospitals for providing
multiple myocardial PET scan procedures. They reported that multiple
myocardial PET procedures require greater hospital resources than
single myocardial PET scans.
Response: Based on our review of the hospital outpatient claims
data from CY 2005 and CY 2006, as well as the clinical characteristics
of CPT code 78492, we do not agree that we should establish a new
clinical APC solely for the multiple myocardial PET scans. Our claims
data for this final rule with comment period showed a total of 2,808
procedures reported with the multiple scan CPT code 78492. Conversely,
our claims data showed only a combined total of 286 procedures reported
with the single scan CPT codes 78459 and 78491.
We note that our final median cost for this APC is approximately
$1,384, which is significantly lower than the proposed rule median cost
for the APC. According to our final ratesetting policies in which we
included CPT code 93017 on the bypass list as discussed in section
II.1.b of this final rule with comment period, we based APC 0307's
final median cost on 1,832 single claims out of 3,094 CY 2006 claims
for myocardial PET procedures. Due to our bypassing of CPT code 93017
for the cardiovascular stress test commonly reported with myocardial
PET scans, we were able to use almost twice the number of claims to
develop the final median cost based on claims from a large number of
hospitals in comparison with the proposed rule, and almost all of those
additional single claims were for multiple myocardial PET scan
services. As discussed in section II.A.4.c.(5) of this final rule
comment period, the final median cost for APC 0307 was also calculated
only from those claims for myocardial PET scan procedures that also
contained a HCPCS code for a diagnostic radiopharmaceutical. The median
cost of approximately $1,384 compares favorably to our CY 2007
estimated average total payment of $1191 for these services, consisting
of approximately $731 for the scan (APC 0307) and approximately $460
(average estimate of charges reduced to cost) for the commonly used
diagnostic radiopharmaceutical A9555 (Rubidium Rb-82-diagnostic, per
study dose, up to 60 millicuries). Therefore, we believe that the final
median cost of APC 0307 for the scans and associated diagnostic
radiopharmaceuticals appropriately reflects the hospital resources
associated with providing myocardial PET scans to Medicare
beneficiaries in cost-efficient settings and is adequate to ensure
appropriate access to these services for Medicare beneficiaries.
The CY 2008 median cost for APC 0307 of approximately $1,384 is
very similar to the median cost of CPT code 78492 of $1,467, so we do
not believe that the assignment of the relatively small number of
generally lesser cost single scan claims to APC 0307 significantly
reduces the payment rate for multiple scan studies. In addition, as
discussed in section II.A.2. of this final rule with comment period, we
are attempting to reduce the number of low volume APCs under the OPPS
to promote the stability of payment rates. If we were to create a new
clinical APC for multiple myocardial PET scans, APC 0307 for single
scan studies would become a very low volume APC. We continue to believe
that the assignment of CPT codes 78459, 78491, and 78492 to a single
clinical APC for CY 2008 remains appropriate because the CY 2006 claims
data do not support a resource differential among significant
myocardial PET services that would necessitate the placement of single
and multiple PET scan procedures into two separate clinical APCs.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to provide
payment for all myocardial PET scans through APC 0307, with a CY 2008
median cost of approximately $1,384, as shown in Table 20.
Table 20.--Final CY 2008 APC Assignments for Myocardial Pet Scans
----------------------------------------------------------------------------------------------------------------
Final CY
HCPCS code Short descriptor CY 2007 SI CY 2007 CY 2007 APC Final CY 2008 Final CY 2008 APC
APC median cost SI 2008 APC median cost
----------------------------------------------------------------------------------------------------------------
78459.......... Heart muscle S......... 0307 $727 S............. 0307 $ 1,384
imaging (PET).
78491.......... Heart image S......... 0307 $727 S............. 0307 $ 1,384
(pet), single.
78492.......... Heart image S......... 0307 $727 S............. 0307 $ 1,384
(pet), multiple.
----------------------------------------------------------------------------------------------------------------
[[Page 66719]]
d. Nonmyocardial Positron Emission Tomography (PET) Scans (APC 0308)
For CY 2008, we proposed to continue to assign the nonmyocardial
PET scans to APC to 0308 (Non-Myocardial Positron Emission Tomography
(PET) Imaging), with a proposed payment rate of approximately $1,107,
specifically CPT codes 78811 (Tumor imaging, positron emission
tomography (PET); limited area (eg, chest, head/neck)), 78812 (Tumor
imaging, positron emission tomography (PET); skull base to mid-thigh)),
78813 (Tumor imaging, positron emission tomography (PET); whole body)),
and 78608 (Brain imaging, positron emission tomography (PET); metabolic
evaluation). We note that this proposed payment will include payment
for the diagnostic radiopharmaceuticals used in the PET scans. APC 0308
will also include concurrent PET/CT procedures. Refer to section
III.C.2.a. of this final rule with comment period for further
discussion of the CY 2008 OPPS assignment of concurrent PET/CT
procedures.
We received several public comments concerning this proposal. A
summary of the public comments and our responses follow.
Comment: Several commenters agreed with the placement of CPT codes
78811, 78812, and 78813 in APC 0308; however, some commenters requested
that CMS reassign CPT code 78608 to a new clinical APC for PET brain
imaging.
Response: We disagree with the commenters' suggestion that we
should create a separate clinical APC for CPT code 78608. Brain PET
scan services have historically been assigned to the same APCs as other
nonmyocardial PET services for a number of years, initially to the same
New Technology APCs and for CY 2007 to the same clinical APC. Analysis
of our hospital outpatient claims data from CY 2006 reveals that the
median cost of approximately $1,046 for CPT code 78608 falls within the
range of the HCPCS-specific median costs, approximately $1,004 to
$1,240, for the other PET procedures also assigned to APC 0308. 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. The
OPPS is a prospective payment system that provides payment for groups
of services that share clinical and resource 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.
After considering the public comments received, we are finalizing
our proposal, without modification, including assignment of CPT code
78608 to APC 0308, with a CY 2008 median cost of approximately $1,044.
e. Proton Beam Therapy (APCs 0664 and 0667)
For CY 2008, we proposed to pay for the following four CPT codes
for proton beam therapy: 77520 (Proton treatment delivery; simple,
without compensation); 77522 (Proton treatment delivery; simple, with
compensation); 77523 (Proton treatment delivery; intermediate); and CPT
77525 (Proton treatment delivery; complex). We proposed to continue to
assign the simple proton beam therapy procedures to APC 0664 (Level I
Proton Beam Radiation Therapy), with a proposed median cost of
approximately $845, and the intermediate and complex proton beam
therapy procedures to APC 0667 (Level II Proton Beam Radiation
Therapy), with a proposed median cost of approximately $1,012. The CY
2007 payment rates for these APCs are approximately $1,161 and $1,389,
respectively. We also proposed to make an exception to the 2 times rule
for APC 0664, as we did in CYs 2006 and 2007.
We received several public comments concerning this proposal. A
summary of the public comments and our responses follow.
Comment: One commenter expressed concern that the CY 2008 proposed
payment rates for APCs 0664 and 0667 are approximately 27 percent lower
than the CY 2007 payment rates for these same APCs. The commenter
characterized proton beam therapy as an extremely complex and expensive
technology that is currently offered in only two hospitals. The
commenter asked CMS to reevaluate the claims data and its analysis of
the median costs contained in those claims data for errors. The
commenter asserted that if the data and rate calculations were verified
as valid, CMS should take into consideration that for any service
provided by only two hospitals, the payment rates for the service will
be highly dependent on the idiosyncrasies of the billing and charging
practices of those two facilities. The commenter stated that a 27
percent reduction in payment would discourage, if not eliminate, the
adoption of this technology by other providers. In addition, the
commenter offered support for the proposal to designate APC 0664 as an
exception to the 2 times rule for CY 2008.
Another commenter reviewed its proton beam therapy claims, charges,
and cost data, and determined that the CY 2008 proposed median costs
for APCs 0664 and 0667 appropriately reflect the cost of this
technology.
Response: In response to one commenter's concern about the validity
of our data and our ratesetting analyses, we examined the claims and
cost reports for proton beam therapy and verified our calculations.
Consistent with the other commenter's examination of its own claims,
charges, and costs, we found both the data and our calculation of the
median costs to be accurate for APCs 0664 and 0667. We note that the
median costs for relatively low volume APCs, such as APCs 0664 and
0667, often fluctuate from year to year, in part due to the variability
created by a small number of claims. We agree with the commenter that
because our standard ratesetting methodology is based on OPPS claims,
the payment rates for those services provided by only a few hospitals
to Medicare beneficiaries are dependent on the particular costs and
charging practices of that small subset of hospitals paid for the
services under the OPPS. Therefore, the small number of hospitals
providing proton beam therapy also may contribute to additional
variation in payment rates as those hospitals' charging and cost
reporting practices evolve over time. As more hospitals adopt this
technology, we expect that the fluctuation in payment for APCs 0664 and
0667 will be moderated by the increased number of observations for
similar services and the incorporation of claims from a larger number
of hospitals in the ratesetting process.
We note that neither of these APCs violate the 2 times rule based
on the CY 2008 final rule data because the volume of CPT code 77520 is
such a small percentage of claims for APC 0664. The law permits
exceptions to the 2 times rule for services that are low volume, which
we generally have considered as having a single bill frequency that is
less than or equal to 1,000, or less than or equal to 99 if the service
constitutes less than 2 percent of the single bill frequency for an
APC. CPT code 77520 has a single bill frequency of 188 in the CY 2008
OPPS data and constitutes only 1 percent of the single claims in the
APC. Therefore, there is no 2 times violation in APC 0664.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to assign CPT
codes 77520 and 77522 to APC 0664, with a median cost of approximately
$807, and to assign CPT codes 77523 and 77525 to APC 0667, with a
median cost of approximately $965.
[[Page 66720]]
6. Ocular and Ear, Nose, and Throat Procedures
a. Amniotic Membrane for Ocular Surface Reconstruction (APC 0244)
We proposed to assign HCPCS code V2790 (Amniotic membrane for
surgical reconstruction, per procedure) status indicator ``N''
(packaged) for CY 2008 and to assign its related CPT procedure codes to
APC 0244 (Corneal Transplant). The proposed status indicators for the
item and procedures and the proposed APC assignments for the procedures
were the same as their CY 2007 OPPS treatment.
We received several comments on the proposed OPPS treatment of
HCPCS code V2790 for CY 2008. A summary of the public comments and our
response follow.
Comment: Several commenters requested that CMS consider assigning a
status indicator of ``F'' (paid at reasonable cost) to HCPCS code V2790
and creating a separate APC for amniotic membrane transplantation
procedures that includes the costs of amniotic membrane tissue. They
compared V2785 (Processing, preserving and transporting corneal tissue)
and V2790, noting a difference in payment policy and status indicator
assignments for the two types of tissues used for ocular surface
transplant. That is, HCPCS code V2785, which is assigned status
indicator ``F'' and HCPCS code V2790, which is assigned status
indicator ``N,'' are not treated similarly with regard to status
indicator assignments and OPPS payment policy. Payment for items and
services assigned status indicator ``N'' is packaged into payment for
the associated procedures, while payment for items and services with
status indicator ``F'' is made at reasonable cost, not under the OPPS.
Another commenter requested that CMS reassign the CPT procedure codes
associated with the amniotic tissue transplant from APC 0244 to a
separate APC. This commenter indicated that the source tissue is not
bundled into the payment for every CPT code in APC 0244, only the
amniotic membrane tissue.
In addition, several commenters were concerned that paying
separately for corneal tissue and not for amniotic membrane tissue
could create a competitive disadvantage and a financial disincentive
for hospitals to treat ocular surface diseases using amniotic membrane
tissue and ultimately would impede beneficiary access to this ocular
reconstructive procedure. Some commenters indicated that HCPCS code
V2790 and its related procedure code, specifically CPT code 65780
(Ocular surface reconstruction; amniotic membrane transplantation), are
not adequately represented in hospital claims data. Despite
instructions from CMS that packaged items and services should be
reported on claims, some commenters believed that hospitals often fail
to report HCPCS code V2790 because payment for HCPCS code V2790 is
packaged with its related procedure code. They argued that the
underreporting of the use of amniotic membrane tissue, which includes
the costs of procuring, processing, storing, and distributing the
product, leads to inadequate payment for CPT code 65780. Some
commenters recommended that CMS establish claims processing edits to
ensure the presence of the tissue HCPCS code and a charge for the item
on claims for the ocular reconstruction procedure. One commenter
indicated that the costs for amniotic membrane tissue can vary widely,
similar to corneal tissue, and that the procurement of the tissue adds
to the highly variable costs because hospitals require different sized
tissues to accommodate various treatment and patient requirements.
These commenters requested that CMS reassign HCPCS code V2790 from
status indicator ``N'' to ``F'' and also create a separate APC
specifically for amniotic membrane transplantation procedures for CY
2008.
Response: 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. Unlike
corneal tissue, we believe that amniotic tissue is a supply with stable
and predictable costs. We do not consider the circumstances of amniotic
tissue to be like those of corneal tissue, and consider it appropriate
to continue to package the payment for amniotic tissue into payment for
its related procedure code.
We examined CY 2008 proposed rule claims, derived from CY 2006, for
CPT code 65780, with and without HCPCS code V2790. While most claims
did not specifically include HCPCS code V2790, the median costs for
claims with and without HCPCS code V2790 were reasonably close and
consistent with the costs of other services assigned to APC 0244.
Specifically, claims with HCPCS code V2790 had a median cost of
approximately $2,553, while claims without HCPCS code V2790 had a
median cost of approximately $2,063. The median line-item cost of HCPCS
code V2790 was $506, relatively consistent with the difference in cost
between the claims with and without HCPCS code V2790. Based on our
analysis, the proposed rule median cost of approximately $2,409 for all
procedures in APC 0244, which would not include the costs of corneal
tissue but would incorporate the costs of amniotic membrane tissue, is
very close to the median cost of the amniotic tissue transplant
procedure claims that include the HCPCS code for amniotic membrane
tissue. The CY 2008 APC 0244 final rule median cost of approximately
$2,359 is consistent with the APC's proposed rule cost.
Based on our claims data from CY 2006, we believe that the current
and proposed packaged status of HCPCS code V2790 is appropriate based
on resource and clinical considerations. We also believe that the
proposed composition of APC 0244, dominated by claims for corneal
transplant procedures, reflects appropriate clinical and resource
homogeneity. While some commenters were concerned with hospitals not
reporting HCPCS code V2790 when reporting CPT code 65780, we do not
believe that we should create a claims processing edit in this
instance. We create device edits, when appropriate, for procedures
assigned to device-dependent APCs, where those APCs have been
historically identified under the OPPS as having very high device
costs. Because APC 0244 is not a device-dependent APC and the costs of
the procedure with and without HCPCS code V2790 are relatively close,
we will not create edits. We remind hospitals that they must report all
of the HCPCS codes that appropriately describe the items used to
provide services, regardless of whether the HCPCS codes are packaged or
paid separately.
After consideration of the public comments received, we are
finalizing our proposed CY 2008 payment policies, without modification,
for HCPCS codes V2785 and V2790 as reflected in their status
indicators, as well as the proposed configuration of APC 0244. We are
also changing the APC title for APC 0244 from ``Corneal
[[Page 66721]]
Transplant'' to ``Corneal and Amniotic Membrane Transplant,'' effective
January 1, 2008, to ensure that the title better describes all
procedures assigned to that APC.
b. Keratoprosthesis (APC 0293)
CPT code 65570 (Keratoprosthesis) describes the surgical procedure
for implantation of an artificial cornea, also known as a
keratoprosthesis. In the CY 2007 OPPS/ASC final rule with comment
period, we indicated that we were implementing device edits in CY 2007
for CPT code 65770 to ensure that all claims for CPT code 65570 in CY
2007 and after include charges for a required device (71 FR 68053). For
CY 2008, we proposed continued assignment of CPT code 65570 to APC 0293
(Level V Anterior Segment Eye Procedures), with a proposed payment rate
of approximately $5,290. The CY 2007 payment rate for APC 0293 is
approximately $3,196.
We received one public comment on our CY 2008 proposal for CPT code
65770. A summary of the public comment and our response follow.
Comment: One commenter expressed concern that the procedure
described by CPT code 65570 required significant implantation of a
costly device, but it was not assigned to a device-dependent APC. The
commenter stated that assignment to a nondevice-dependent APC may
result in inadequate payment rates in the ASC setting. The commenter
noted that the revised ASC payment methodology, which will be
implemented in CY 2008, includes an exception to the standard
ratesetting methodology for device-intensive procedures that allows
only the service portion of the procedure to be reduced by the ASC
budget neutrality adjustment to reflect the relatively constant price
of medical devices across hospital outpatient and ASC settings of care.
Device-intensive procedures are defined as those procedures assigned to
device-dependent APCs under the OPPS for payment purposes, where the
APC device cost is greater than 50 percent of the APC median cost. The
commenter pointed out that by assigning CPT code 65570 to a non-device-
dependent APC under the OPPS, the procedure did not qualify as device
intensive for ASC payment purposes. The commenter concluded that the
entire payment rate for the procedure would be reduced by the ASC
budget neutrality adjustment, rather than just the service portion, in
contrast to other procedures assigned to APCs for which the device
costs constitute a significant portion of the total procedure costs.
Response: We agree with the commenter that the procedure described
by CPT code 65770 requires the implantation of a device, and that a
significant portion of the total cost of keratoprosthesis implantation
procedures is likely to be attributable to device costs. Currently CPT
code 65570 is assigned to APC 0293 under the OPPS, where it is the only
procedure in the APC. There also are two device codes for reporting
keratoprostheses, HCPCS code C1818 (Integrated Keratoprosthesis) that
describes the expired pass-through device category that was created in
CY 2003 and HCPCS code L8609 (Artificial cornea) that was first
available for reporting in CY 2007. It is not possible to calculate a
device percentage for APC 0293 for CY 2008 that reflects the full costs
of the devices implanted in CY 2006 because there was no device code
that described all possible devices that could be implanted in the
procedure at that time.
As we stated in the CY 2007 OPPS/ASC final rule with comment
period, when 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 commonly institute
device edits that prevent payment of claims that do not include both
the procedure and an acceptable device code (71 FR 68053). We
implemented device edits in CY 2007 for APC 0293, the first year that
device HCPCS codes that describe all possible devices that could be
used to perform the procedure were available, and we agree with the
commenter that it would be most consistent with our established device
editing policy to designate APC 0293 as device-dependent. However, we
are unable to consider only CY 2006 claims for CPT code 65570 that
contain a device HCPCS code for CY 2008 ratesetting for the APC. If we
were to follow our usual ratesetting methodology for device-dependent
APCs, we could be systematically and incorrectly excluding claims for
CPT code 65570 that may have been correctly coded at the time by
hospitals implanting a two-part keratoprosthesis not described by the
only available HCPCS code, specifically C1818.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, with modification. We are assigning
CPT code 65570 to APC 0293 as proposed. In addition, we are designating
APC 0293 as a device-dependent APC, with a median cost of approximately
$5,335.
c. Palatal Implant (APC 1510)
In Addendum B to the CY 2008 proposed rule (72 FR 43018), we
proposed to pay $850 for HCPCS code C9727 (Insertion of implants into
the soft palate; minimum of three implants) through its assignment to
New Technology APC 1510 (New Technology--Level X ($800-$900)). This is
the same APC assignment for the service as its CY 2007 placement.
We received one comment on our CY 2008 payment proposal for HCPCS
code C9727. A summary of the comment and our response follow.
Comment: One commenter considered the proposed CY 2008 payment rate
for HCPCS code C9727 to be inappropriate based on the costs of the
clinical staff, supplies, equipment, and overhead required to perform
the procedure. The commenter reported that, based on its estimate that
used the MPFS Practice Expense Database as a reference, the appropriate
median cost for this procedure should be between $1,100 and $1,200. The
commenter submitted a categorized list of items involved in performing
the procedure to CMS, along with approximate costs for each category.
In addition, the commenter asked CMS to reassign HCPCS code C9727 to
New Technology APC 1514 (New Technology--Level XV ($1200-$1300)) for CY
2008 because the commenter believed that the payment for this APC would
appropriately reflect the complexity and resource costs associated with
performing this procedure.
Response: We assign a new procedure to a New Technology APC when we
do not have adequate claims data upon which to determine the median
cost of performing a procedure and there is no appropriate clinical APC
for its assignment based on clinical and resource homogeneity
considerations. We perform our own cost analysis and cost estimate, in
addition to taking the project costs that may be submitted in a New
Technology APC application into consideration. As we stated in our
November 30, 2001 final rule (66 FR 59900), concerning the placement of
new services into New Technology APCs in response to an application,
``We will not limit our determination of the cost of the procedure to
information submitted by the application. Our staff will obtain
information on cost from other appropriate sources before making a
determination of the cost of the procedure to hospitals.'' We received
a New Technology APC application from the manufacturer of palatal
implants required for the Pillar[supreg] Procedure. Consistent with our
customary practice,
[[Page 66722]]
we compared the estimated hospital resources, including procedure room
time, personnel, device costs, and other resources of the new procedure
to various other OPPS procedures for which we have historical claims
data. We believed that, based on this analysis, a payment rate of $850
was appropriate based on all cost and utilization information available
to us regarding the palatal implant procedure and other services
provided in the hospital outpatient setting. Consequently, we assigned
HCPCS code C9727 to New Technology APC 1510, effective October 1, 2006.
Analysis of our hospital data for claims submitted for CY 2006
indicates that the palatal implant procedure was rarely performed on
Medicare beneficiaries in the last quarter of that year when specific
OPPS payment was first available. OPPS claims for services between
October 1, 2006, and December 1, 2006, show that there were only two
claims submitted for HCPCS code C9727. We reexamined the service's
proposed CY 2008 assignment in light of all current information
available to us for this final rule with comment period, and we
conclude that its proposed assignment to New Technology APC 1510
remains appropriate. We will reexamine the claims data for this
procedure next year when we review its APC placement in preparation for
the annual CY 2009 OPPS update.
Furthermore, the MPFS applies a very different methodology for
establishing the payment for the physician's office practice expenses
associated with a procedure, specifically considering the individual
costs of the inputs, whereas the OPPS generally pays based on relative
payment weights calculated from hospitals' costs as determined from
claims data. Thus, comparisons between the MPFS and OPPS payments for
services are not appropriate. While the palatal implant procedure is a
relatively new service under the OPPS, the procedure resembles other
OPPS services for which cost data are currently available.
Therefore, after consideration of all the public comments received,
we are finalizing our CY 2008 proposal, without modification, to assign
HCPCS code C9727 to New Technology APC 1510 with a payment rate of
$850.
7. Orthopedic Procedures
a. Arthroscopic Procedures (APCs 0041 and 0042)
For CY 2008, we proposed two primary APCs for arthroscopic
procedures, APC 0041 (Level I Arthroscopy), comprised of 49 procedures
with a CY 2008 proposed payment rate of approximately $1,876, and APC
0042 (Level II Arthroscopy), comprised of 17 procedures with a proposed
payment rate of approximately $3,043. The CY 2007 payment rates for
these APCs 0041 and 0042 are approximately $1,759 and $2,797,
respectively. While we proposed to assign the majority of arthroscopic
procedures to these APCs for CY 2008, we also proposed to continue the
assignment of several arthroscopic procedures to APC 0053 (Level I Hand
Musculoskeletal Procedures), with a proposed CY 2008 payment rate of
approximately $1,071. The CY 2007 payment rate for APC 0053 is
approximately $993.
We received one public comment on our CY 2008 proposed
configuration of arthroscopy APCs. A summary of the public comment and
our response follow.
Comment: A commenter stated that the current configuration of
arthroscopic procedures assigned to APCs 0041, 0042, and 0053 fails to
appropriately recognize the distinct clinical and resource features of
the wide range of arthroscopic procedures now being provided to
Medicare beneficiaries. The commenter requested that CMS create new
arthroscopy APCs and reconfigure the current assignment of arthroscopic
procedures to ensure that the arthroscopy APCs are clinically
homogenous and contain only those procedure that are similar in
resource utilization. Specifically, the commenter requested that CMS
restructure the arthroscopy APCs to reflect the following clinical
categories: diagnostic arthroscopies, lower extremity versus upper
extremity arthroscopies, and arthroscopies with implants. The commenter
suggested that each clinical distinction be divided further into three
levels of resource utilization, for a total of 9 new APCs for
arthroscopy procedures with recommended payment ranging from $1,530 to
$4,100. According to the commenter, these clinical distinctions
parallel the distinctions CMS has created for other classes of
procedures, including other orthopedic procedures, and would more
accurately and equitably reflect the clinical characteristics and
resource utilization of the services rendered.
Response: In response to the concerns raised by the commenter, we
reviewed the clinical characteristics and hospital costs from CY 2006
claims data for all procedures proposed for CY 2008 assignment to APCs
0041, 0042, and 0053. In considering the commenter's recommended APC
configurations, we identified several procedures that were assigned to
APCs 0041 and 0053 with median costs and clinical characteristics that
were more similar to procedures assigned to other clinical APCs than
the APCs to which we proposed their assignment. Therefore, for CY 2008,
we will reassign 11 arthroscopic procedures that are currently in APC
0041 to APC 0042, and we will reassign 3 arthroscopic procedures that
are currently in APC 0053 to 0041, as reflected in Table 21 below.
While we appreciate the commenter's suggestion for nine new APCs for
arthroscopic procedures, we believe that the existing clinical APCs,
with the modifications included in Table 21 that assign procedures to
the larger groups in a way that is generally consistent with the
commenter's more specific recommended groupings, sufficiently account
for the different clinical and resource characteristics of these
procedures. Furthermore, to reduce the size of the APC payment groups
and establish new clinical APC payment groups to pay more precisely
would be inconsistent with our overall strategy to encourage hospitals
to use resources more efficiently by increasing the size of the payment
bundles.
After consideration of the public comment received, we are
modifying our CY 2008 proposal and will reassign several arthroscopic
procedures to APCs 0041 and 0042, as displayed in Table 21 below.
Table 21.--CY 2008 APC Reassignment of Arthroscopic Procedures
----------------------------------------------------------------------------------------------------------------
CY 2007 APC CY 2008 APC
HCPCS code Short descriptor CY 2007 APC median CY 2008 APC median
assignment cost assignment cost
----------------------------------------------------------------------------------------------------------------
29819..................... Shoulder arthroscopy/surgery.... 0041 $1,749 0042 $2,876
29820..................... Shoulder arthroscopy/surgery.... 0041 1,749 0042 2,876
29821..................... Shoulder arthroscopy/surgery.... 0041 1,749 0042 2,876
29823..................... Shoulder arthroscopy/surgery.... 0041 1,749 0042 2,876
[[Page 66723]]
29825..................... Shoulder arthroscopy/surgery.... 0041 1,749 0042 2,876
29847..................... Wrist arthroscopy/surgery....... 0041 1,749 0042 2,876
29856..................... Tibial arthroscopy/surgery...... 0041 1,749 0042 2,876
29860..................... Hip arthroscopy, dx............. 0041 1,749 0042 2,876
29861..................... Hip arthroscopy/surgery......... 0041 1,749 0042 2,876
29891..................... Ankle arthroscopy/surgery....... 0041 1,749 0042 2,876
29892..................... Ankle arthroscopy/surgery....... 0041 1,749 0042 2,876
29900..................... Mcp joint arthroscopy, dx....... 0053 987 0041 1,811
29901..................... Mcp joint arthroscopy, surg..... 0053 987 0041 1,811
29902..................... Mcp joint arthroscopy, surg..... 0053 987 0041 1,811
----------------------------------------------------------------------------------------------------------------
b. Closed Fracture Treatment (APC 0043)
For CY 2008, we proposed to continue the assignment of various CPT
codes that describe closed treatment of fractures of the fingers, toes,
and trunk to APC 0043 (Closed Treatment Fracture Finger/Toe/Trunk),
with a proposed payment rate of about $119. We did not propose any CPT
code reassignment changes for APC 0043.
We received one public comment on our proposed CY 2008
configuration of APC 0043. A summary of the public comment and our
response follow.
Comment: A commenter expressed concern about the wide variety of
procedures assigned to APC 0043, which the commenter claimed ranged
from $1 to $3,000 in cost. The commenter disapproved of CMS assigning
one APC for various types of fracture treatments as the commenter
asserted that the costs associated with finger treatments, hip
dislocations, and spinal fractures vary significantly. The commenter
indicated specifically that the costs associated with spinal fractures
are significantly greater than the costs associated with finger or toe
fractures. The commenter believed that grouping all of these procedures
in one clinical APC violated the 2 times rule, and that continuing to
except APC 0043 from the 2 times rule was not appropriate. To pay
appropriately for these procedures under the current OPPS, the
commenter recommended that CMS divide the procedures currently assigned
to APC 0043 among several APCs, because of the existing large
variations in resource costs for the procedures.
Response: We thank the commenter for bringing this concern to our
attention. We agree with the commenter that grouping all of the closed
fracture treatment procedures in one APC may not most accurately
distinguish the more expensive from the less resource-intensive
fracture treatment procedures. We note that while there are about 150
procedures assigned to APC 0043, only 13 procedures are significant
procedures with the frequency necessary to assess the APC's alignment
with the 2 times rule. The remainder of the procedures are low volume
and, therefore, not significant procedures in the APC for purposes of
evaluating the APC by applying the 2 times rule. The median costs of
the significant procedures in APC 0043 for CY 2008 range from about $68
to $248. This particular APC has been excepted from the 2 times rule
for the past 6 years under the OPPS, and we have not previously
received public comments regarding the structure of this APC over the
past several years. The commenter did not make a specific
recommendation regarding alternative APC configurations. Because APC
0043 contains so many different fracture treatment procedures with low
volume, we are concerned that any restructuring for CY 2008 without the
benefit of public comment could lead to APCs that do not reflect
improved clinical and resource homogeneity over the proposed
configuration; therefore, we will not establish a different APC
configuration for CY 2008. However, we are specifically inviting public
comment on potential alternative APC configurations for the services
currently assigned to APC 0043 for the CY 2009 APC review process. We
also plan to bring this APC issue to the attention of the APC Panel at
its winter 2008 meeting and will request its input as to how to
appropriately categorize the procedures in APC 0043.
After consideration of the public comment received, we are
finalizing, without modification, our proposed configuration of APC
0043, with a median cost of about $111 for CY 2008.
c. Insertion of Posterior Spinous Process Distraction Device (APC 0050)
We proposed to assign CPT codes 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) to APC 0050 (Level II
Musculoskeletal Procedures Except Hand and Foot), with a proposed
payment rate of approximately $1,868. These two codes were new in CY
2007, where they were assigned to APC 0050 on an interim final basis.
We created a new device category, specifically, C1821 (Interspinous
process distraction device (implantable)) for transitional pass-through
payment, effective January 1, 2007, which we expected to be reported
with CPT codes 0171T and 0172T. This pass-through device category will
continue to be paid at hospital charges adjusted to cost for CY 2008,
as discussed in section IV.A.1.b. of this final rule with comment
period.
We received several public comments on our CY 2008 proposed APC
assignments for CPT codes 0171T and 0172T. A summary of the public
comments and our response follow.
Comment: Some commenters disagreed with our proposed APC
assignments for CPT codes 0171T and 0172T, and indicated that these
procedures should be reassigned from APC 0050 to APC 0208 (Laminotomies
and Laminectomies), which had a proposed payment rate of approximately
$3,036 for CY 2008. The commenter asserted that the spinous distraction
device insertion is clinically different and involves greater hospital
resources than the other procedures assigned to APC 0050. This
commenter cited one procedure in APC 0050, specifically vertebroplasty,
claiming that its costs are significantly lower than the spinous
process distraction device procedure. The commenter claimed that the
vertebroplasty procedure is one that involves an injection procedure
that is
[[Page 66724]]
performed in 30 minutes and does not involve implanting a spinal
device. Alternatively, the commenter explained that inserting a spinous
process distraction device requires an hour in the operating room and
involves implanting a device in the spine. Several commenters reported
that the spinous process distraction device insertion is similar to a
laminectomy procedure in that both procedures involve the spinal
processes and take approximately 1 hour to perform. These commenters
requested that CMS reassign CPT codes 0171T and 0172T to APC 0208 based
on clinical and cost considerations.
Response: We carefully analyzed the CY 2006 claims data for other
musculoskeletal procedures under the OPPS, and we believe that CPT
codes 0171T and 0172T are appropriately assigned to APC 0050, based on
both clinical and expected resource considerations. We do not agree
with some commenters that these minimally invasive procedures to insert
a spinal device are similar to the procedures that are currently
assigned to APC 0208, which are generally significant open surgical
procedures on the spine. We believe that the hospital's nondevice costs
and the clinical characteristics of CPT codes 0171T and 0172T more
closely align with the less invasive musculoskeletal procedures
presently assigned to APC 0050.
We will continue pass-through payment status, initially implemented
in January 2007, for the spinous process distraction device (C1821)
reported with CPT codes 0171T and 0172T through CY 2008. Separate
payment for HCPCS code C1821 will be made 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 will be packaged into the procedural
payment for its implantation, specifically CPT codes 0171T and 0172T.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to assign CPT
codes 0171T and 0172T to APC 0050, with a median cost of approximately
$1,836.
d. Intradiscal Annuloplasty (APC 0050)
For CY 2008, we proposed to assign the intradiscal electrothermal
(IDET) annuloplasty procedures, specifically those described by CPT
codes 22526 (Percutaneous intradiscal electrothermal annuloplasty,
unilateral or bilateral including fluoroscopic guidance; single level)
and 22527 (Percutaneous intradiscal electrothermal annuloplasty,
unilateral or bilateral including fluoroscopic guidance; one or more
additional levels (List separately in addition to code for primary
procedure)) to APC 0050 (Level II Musculoskeletal Procedures Except
Hand and Foot), with a proposed payment rate of approximately $1,868
for CY 2008. These CPT codes were new for CY 2007, when they were first
assigned to APC 0050 under the OPPS on an interim final basis.
We received several public comments on our CY 2008 proposed APC
assignments for CPT codes 22526 and 22527. A summary of the public
comments and our response follow.
Comment: Several commenters disagreed with the proposed assignment
for CPT codes 22526 and 22527 and recommended that these procedures be
reassigned to APC 0051 (Level III Musculoskeletal Procedures Except
Hand and Foot), which had a proposed CY 2008 payment rate of
approximately $2,777. These commenters believed that the hospital costs
associated with IDET are relatively higher than the payment associated
with APC 0050. One commenter who provided its price list reported that
the cost of one disposable catheter used in the procedure is
approximately $1,800. The commenter indicated that APC 0051 would more
accurately pay hospitals for the IDET procedure. Another commenter
indicated that the other procedures in APC 0051 are similar to the IDET
procedure based on clinical homogeneity and resource costs.
Response: CPT codes 22526 and 22527 were created effective January
1, 2007. Prior to CY 2007, the IDET procedure was described by CPT code
0062T, which was implemented on January 1, 2005. The initial code long
descriptor for CPT code 0062T in CY 2005 was ``Percutaneous intradiscal
annuloplasty, any method, unilateral or bilateral including
fluoroscopic guidance; single level.'' However, in CY 2007, the CPT
Editorial Panel revised this descriptor to ``Percutaneous intradiscal
annuloplasty, any method except electrothermal, unilateral or bilateral
including fluoroscopic guidance; single level'' to appropriately
differentiate between electrothermal and non-electrothermal methods.
Following the descriptor revision, CPT codes 22526 and 22527 described
the electrothermal methodology for percutaneous intradiscal
annuloplasty, while CPT code 0062T described the non-electrothermal
methodology.
Since the code descriptor change did not occur until CY 2007,
hospital outpatient claims from CY 2006 for CPT code 0062T describe
both electrothermal and non-electrothermal methods. Based on our review
of the hospital outpatient claims from CY 2006 and CY 2005,
percutaneous intradiscal annuloplasty is performed infrequently in the
hospital outpatient setting for the Medicare population. Claims from CY
2006 show a median cost of approximately $1,019 for CPT code 0062T
based on 44 single claims, and a median cost of approximately $2,034
based on only 28 single claims for CY 2005.
We believe, based on our review of the clinical characteristics and
historical hospital costs for percutaneous intradiscal annuloplasty and
other musculoskeletal procedures assigned to APCs 0050 and 0051, that
the most appropriate APC assignment for percutaneous intradiscal
annuloplasty procedures, whether electrothermal or non-electrothermal,
is APC 0050.
After considering the public comments received, we are finalizing
our CY 2008 proposal, without modification, to assign CPT codes 22526
and 22527 to APC 0050, with a median cost of approximately $1,836.
e. Kyphoplasty Procedures (APC 0052)
For CY 2008, we proposed to assign CPT codes 22523 (Percutaneous
vertebral augmentation, including cavity creation (fracture reduction
and bone biopsy included when performed) using mechanical device, one
vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty);
thoracic), 22524 (Percutaneous vertebral augmentation, including cavity
creation (fracture reduction and bone biopsy included when performed)
using mechanical device, one vertebral body, unilateral or bilateral
cannulation (eg, kyphoplasty); lumbar), and 22525 (Percutaneous
vertebral augmentation, including cavity creation (fracture reduction
and bone biopsy included when performed) using mechanical device, one
vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty);
each additional thoracic or lumbar vertebral body (List separately in
addition to code for primary procedure)) to APC 0052 (Level IV
Musculoskeletal Procedures Except Hand and Foot) with a proposed
payment rate of approximately $5,010.
We received one public comment on our CY 2008 proposal for CPT
codes 22523, 22524, and 22525. A summary of the public comment and our
response follow.
Comment: Some commenters expressed concern about the accuracy of
hospital charge data for these procedures. Because of charge
compression, the commenters believed that the current data collected
from hospital charges do not accurately
[[Page 66725]]
reflect the true costs of the kyphoplasty procedures. The commenters
appreciated CMS'' attention in reviewing and placing these procedures
in an appropriate APC for CY 2008; however, they believed that charge
compression directly contributes to inaccurate and reduced payment
rates for the services. One commenter explained that procedures that
involve the use of expensive medical devices, whereby hospitals apply
smaller mark-up rates to higher-cost medical devices than they do to
lower-cost supplies used in procedures, results in charge compression.
Because the current OPPS payment methodology is to calculate the
payment weight for an APC based on hospital charges adjusted to cost,
the commenters argued that charge compression results in the lowering
of payment rates for procedures that involve the use of expensive
medical devices. These commenters strongly urged CMS to continue to
consider future refinements to the OPPS payment amounts for kyphoplasty
procedures in light of the effects of charge compression.
Response: We thank the commenters for their suggestions and refer
to section II.A.3. of this final rule with comment period for further
discussion on charge compression. Consistent with our update process,
we review hospital outpatient claims data and assign services and items
to appropriate APCs on an annual basis.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to assign CPT
codes 22523, 22524, and 22525 to APC 0052, with a median cost of
approximately $4,997.
8. Vascular Procedures
a. Blood Transfusion (APC 0110)
We have a longstanding policy under the OPPS that blood transfusion
services are billed and paid on a per encounter basis and not by the
number of units of blood products transfused (Internet Only Manual 100-
4, Chapter 4, Section 231.8). Under this policy, a transfusion APC
payment is made to the OPPS provider for transfusing blood products
once per day, regardless of the number of units or different types of
blood products transfused. The OCE ensures only one payment for APC
0110 (Transfusion), regardless of the number of units of CPT code 36430
(Transfusion, blood or blood components) reported by the hospital on a
single date of service. The CPT code 36430 descriptor does not include
``per unit.'' Hence, the median cost for CPT code 36430, which is
assigned to APC 0110, represents the costs of transfusion of blood or
blood products on the same date of service, regardless of how many
units of products are transfused. In addition, for payment of the
transfusion service, the OCE also requires the claim to contain a Level
II HCPCS P-code for a blood product on the same date of service as the
transfusion procedure.
At its March 2007 meeting, the APC Panel recommended that CMS
investigate whether CPT code 36430 should identify when multiple units
are transfused and trigger a discounted payment for the second and
subsequent administration of additional units of blood or blood
components. The APC Panel indicated that the current payment for
transfusion services does not adequately pay hospitals for the costs of
these complex services, and that payment on a per unit basis rather
than on a per encounter basis would result in more accurate and
appropriate payment.
We did not agree with the APC Panel's recommendation, and we
proposed to not accept this recommendation for the CY 2008 OPPS. As
stated in the CY 2008 OPPS/ASC proposed rule (72 FR 42718), we believe
that our current policy of providing a single payment for blood
transfusion, regardless of the number of units transfused, is most
consistent with the goals of a prospective payment system to encourage
and create incentives for efficiency in providing services. Payment for
transfusion services on a per encounter basis encourages the
transfusion of only those blood products that are necessary for the
beneficiary's treatment during the hospital outpatient encounter.
Moreover, the current median cost for the transfusion service,
associated with the transfusion of all blood products furnished on a
date of service, has been set based on the historical reporting of all
charges for transfusion on the same date of service and, therefore,
represents the full cost of an episode of transfusion, rather than the
cost of transfusion of a single unit of blood or blood product. Given
our proposed packaging approach for the CY 2008 OPPS, it would be
inconsistent for us to revise our current transfusion payment policy to
provide separate payment for each unit of blood product transfused,
thereby reducing the size of the current transfusion payment bundle (72
FR 42717 through 42718).
Therefore, for CY 2008 we proposed to maintain our current payment
policy, which bases payment for transfusion on the costs of all
transfusion services furnished on a single date of service and which
examines hospital claims to ensure that payment is provided for only
one unit of CPT code 36430 on a date of service. However, we remind
hospitals that a claim for a single unit of CPT code 36430 should
include charges for all of the hospital resource costs associated with
the totality of transfusion services furnished on the date of service,
so that the payment for one unit of APC 0110 is based on the costs of
all transfusion services provided in a hospital outpatient encounter.
We received several public comments on this proposal to maintain
the current payment policy for blood transfusion services. A summary of
the public comments and our response follow.
Comment: Several commenters requested that CMS reconsider the APC
Panel's recommendation to provide separate payment for the transfusion
of each unit of blood or blood products, as an alternative to CMS'
current, encounter-based payment policy. They stated that the current
policy does not pay OPPS providers adequately for the additional
resources required for hospital outpatient visits involving multiple
transfusions. They suggested that hospitals could report the ``59''
modifier (distinct procedural service) or another appropriate modifier
to indicate that additional transfusions provided on the same day are
distinct from the first transfusion. Some commenters argued that this
would not conflict with the descriptor for CPT code 36430, as hospitals
would only report multiple units of the code when they have performed
more than one distinct transfusion. In contrast, another commenter
noted that CPT guidelines indicate that CPT code 36430 should be
reported once per transfusion regardless of the number of units
administered, and supported CMS' proposal to continue provide one
payment for blood transfusion services based on charges for all
services provided in a hospital outpatient encounter.
One commenter also requested that CMS clarify that hospitals should
charge for blood transfusion and administration services the same way
for both hospital inpatients and outpatients. Another commenter
indicated that hospitals should be able to base blood transfusion
charges according to instructions published when Medicare was first
created. According to the commenter, blood transfusion services were
charged and paid on a per unit basis at that time.
Response: We believe that the current payment policy for blood
transfusion services provides adequate and appropriate payment to OPPS
providers for the additional resources required for hospital outpatient
visits involving multiple transfusions. As described in
[[Page 66726]]
the proposed rule (72 FR 42718), we instruct hospitals to include
charges for all of the hospital resource costs associated with the
totality of transfusion services furnished on a date of service. While
the CPT code descriptor would not preclude hospitals from reporting
multiple units of the code when they have performed more than one
distinct transfusion if they were to consider each unit of blood
transfused to be a distinct transfusion, CPT coding guidelines indicate
that CPT code 36430 should be reported only once per transfusion,
regardless of the number of units administered. We believe that the
median cost calculated from our claims data for blood transfusion
services represents the full cost of an episode of transfusion, rather
than the cost of the transfusion of a single unit of blood or blood
product. We also believe that our current policy of providing a single
payment for blood transfusion, regardless of the number of units
transfused, is most consistent with the goals of a prospective payment
system to encourage and create incentives for efficiency in providing
services. Therefore, for CY 2008, we are implementing our proposal to
maintain our current payment policy, which bases payment for
transfusion on the costs of all transfusion services furnished on a
single date of service and which examines hospital claims to ensure
that payment is provided for only one unit of CPT code 36430 on a date
of service.
Hospital inpatient departments and HOPDs have very different
reporting structures that utilize different coding systems and vary in
other significant ways. Inpatient charges for blood transfusion
services are not relevant to the OPPS. Hospitals are free to set their
charges for all items and services based on their own judgment. As is
the case in other areas of CMS payment policy, reporting instructions
for transfusion services reflect our current payment methodologies,
which have evolved over time, and may not be the same as instructions
published in the past.
In summary, for CY 2008, after consideration of the public comments
received, we are finalizing our proposal, without modification, to
continue to pay hospitals for only one unit of CPT code 36430 on a
single date of service. We are not adopting the APC Panel's March 2007
recommendation to provide a separate payment for each unit of blood or
blood product transfused. Because the payment for one unit of APC 0110,
with a final CY 2008 median cost of approximately $214, is based on the
costs of all transfusion services provided in a hospital outpatient
encounter, we remind hospitals that a claim for a single unit of CPT
code 36430 should include charges for all of the hospital resource
costs associated with the totality of transfusion services furnished on
the date of service.
b. Endovenous Ablation (APC 0092)
For CY 2008, we proposed to pay approximately $1,684 for CPT code
36478 (Endovenous ablation therapy of incompetent vein, extremity,
inclusive of all imaging guidance and monitoring, percutaneous, laser;
first vein treated) through its proposed assignment to APC 0092 (Level
I Vascular Ligation). The proposed APC assignment for this service is
the same as its CY 2007 APC assignment.
We received several public comments on the proposed CY 2008 payment
for CPT code 36478. A summary of the public comments and our response
follow.
Comment: Several commenters believed that the proposed payment rate
for CPT code 36478 was considerably inadequate in view of the expense
associated with the capital equipment required to perform this
procedure. One commenter reported that, based on its estimate that used
the MPFS Practice Expense Database as a reference, the appropriate
placement for this procedure, in comparison with the practice expense
of other endovenous procedures, would be APC 0091 (Level II Vascular
Ligation), which had a CY 2008 proposed payment rate of approximately
$2,781. Another commenter asserted that the other procedures assigned
to APC 0092 bear little resemblance to the procedure described by CPT
code 36478, and that in terms of clinical homogeneity and resource
costs, endovenous ablation therapy of incompetent veins is very similar
to those procedures assigned to APC 0091. The commenter requested that
CMS reassign CPT code 36478 from APC 0092 to APC 0091 for CY 2008.
Response: We disagree with the commenters' argument that CPT code
36478 is less clinically related to procedures in APC 0091 than to
procedures assigned to APC 0092. Procedures assigned to both APCs 0091
and 0092 include a variety of surgical procedures involving veins, and
both APCs include endovenous ablation procedures using different
technologies. Analysis of our CY 2006 hospital claims data results in a
median cost of approximately $2,681 for APC 0091, which is considerably
higher than the HCPCS-specific median cost of approximately $1,713 for
CPT code 36478 based on 984 single claims. However, the median cost of
CPT code 37478 is quite close to the CY 2008 median cost of
approximately $1,626 for APC 0092. We believe that CPT code 36478 is
most appropriately assigned to APC 0092 based on clinical and resource
considerations.
We remind hospitals that in a budget neutral environment, Medicare
does not make payments that fully cover hospitals' costs, including
those for the purchase and maintenance of capital equipment. We rely on
hospitals to make their business decisions regarding acquisition of
expensive 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.
Furthermore, the MPFS applies a very different methodology for
establishing the payment for the physician's office practice expenses
associated with a procedure, specifically considering the individual
costs of the inputs, whereas the OPPS generally pays based on relative
payment weights calculated from hospitals' costs as determined from
claims data. The application of the different methodologies results in
different payment amounts in the two settings. Therefore, comparisons
between the MPFS and OPPS payments for services are not appropriate.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to assign CPT
code 36478 to APC 0092, with a median cost of about $1,626.
c. Insertion of Central Venous Access Device (APC 0625)
For the CY 2008 OPPS, we proposed to assign CPT code 36566
(Insertion of tunneled centrally inserted central venous access device,
requiring two catheters via two separate venous access sites; with
subcutaneous port(s)) to APC 0625 (Level IV Vascular Access
Procedures), as the only code in that APC. The procedure is for the
purpose of implanting a vascular access device that is typically
furnished to persons with end stage renal disease when there are no
suitable access points for hemodialysis. The device that is implanted
is reported under HCPCS code C1881 (Dialysis access system). For CY
2008, we proposed a national unadjusted payment of approximately $5,562
for the service, compared to the CY 2007 national unadjusted payment of
approximately $5,130. As proposed, the payment for the device is
packaged into the payment for APC 0625, a device-dependent APC.
[[Page 66727]]
We received several public comments on the proposed CY 2008 payment
for APC 0625. A summary of the public comments and our responses
follow.
Comment: Several commenters stated that the proposed CY 2008
payment for APC 0625 is excessive and recommended that the CY 2008 APC
payment not exceed the CY 2007 payment. The commenters also recommended
that CMS use external data to establish an appropriate benchmark cost
for HCPCS code C1881. The commenters asked that CMS continue to require
that hospitals must report HCPCS code C1881 on claims on which they
report CPT code 36556. They also asked that CMS establish a payment for
CPT code 36556 that is more stable from year to year. The commenters
indicated that the low volume of these procedures may result in
unstable payment rates over time and that use of external data to
provide a benchmark for the cost of the device could help alleviate
this problem. The commenters claimed that the cost of the device
reported by HCPCS code C1881 is approximately $3,500.
Response: For this final rule with comment period, the median cost
for APC 0625 is approximately $5,143, as compared with the proposed
rule median cost of approximately $5,493. Both the proposed and final
rule medians were calculated using only 8 claims of 479 total bills for
the proposed rule and 535 total bills (of which 325 were potentially
usable single bills) for this final rule with comment period. This is,
in part, because we used only claims that contained the correct device
code, no token charges for the device, and no ``FB'' modifier.
Procedure-to-device edits that return to providers those claims for CPT
code 36556 that do not also contain HCPCS code C1881 did not go into
place until January 1, 2007 and, therefore, were not in place for CY
2006. We recognize that the small number of claims that contain the
HCPCS C-code for the device without which the procedure cannot be
performed may result in a median that is more volatile than is
desirable. However, given that the commenter advises us that the cost
of the device is approximately $3,500 and given that the median we
calculated using final rule data is approximately $5,143, we believe
that it is a reasonable estimate of the cost of the procedure,
including the packaged cost of the device. We expect that the data
available for future OPPS updates, beginning in CY 2009, will include
more claims that report the device HCPCS code and, therefore, future
median costs for APC 0625 may stabilize with additional claims
available for ratesetting.
Comment: One commenter asked that CMS change the short descriptor
for CPT code 36566 to read ``Ins tunneled cath w/subq port'' because
the commenter believed that it is confusing to have multiple CPT codes
with the same short descriptor. The commenter also asked that we revise
the definition for HCPCS code C1881 to read ``Dialysis access system
with subcutaneous port or valve.''
Response: The CPT codes, including the short descriptors, are owned
by the AMA and any change to them is outside of the purview of CMS and
should be addressed to the AMA CPT Editorial Board. HCPCS code C1881
describes the category of dialysis access devices, which is an existing
pass-through device category that expired from pass through status as
of the CY 2003 OPPS. As stated in the November 1, 2005 OPPS final rule
with comment period (70 FR 68631), we revise a code that describes an
existing category of devices (such as C1881) only if such revision is
necessary to distinguish the existing category from a new category of
pass-through devices in instances in which we must create a new
category to describe a device that meets the criteria for pass-through
payment. Therefore, there is no basis in policy to revise the
definition of HCPCS code C1881.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to pay for CPT
code 36566 through device-dependent APC 0625, with a median cost of
approximately $5,143. We will not change the short descriptor for pass-
through device category C1881.
d. Noninvasive Vascular Studies (APC 0267)
For the CY 2008 OPPS, we proposed to pay approximately $158 for
procedures assigned to APC 0267 (Noninvasive Vascular Studies). We also
proposed to pay approximately $420 for services assigned to APC 0269
(Level II Echocardiogram Except Transesophageal).
We received one public comment on our CY 2008 proposal. A summary
of the public comment and our response follow.
Comment: A commenter stated that the vascular ultrasound procedures
included in APC 0267 are grossly underpaid and that the CY 2008 payment
for this APC should be similar to the payment for APC 0269, for which
CMS proposed to pay approximately $417. The commenter indicated that
the services in these two APCs require virtually the same resource
costs. Specifically, the commenter explained that the equipment and
software are equivalent and have similar costs, and in some facilities,
the same equipment is used for the services in both APCs. According to
the commenter, the technicians performing the studies in both APCs are
of the same skill level and the associated cost is the same. The
commenter claimed that the pay scale that CMS uses for purposes of
establishing the MPFS RVUs for the procedures differs by only 2 cents
per hour. The commenter asserted that the time scheduled for the
procedures is virtually identical and that the supplies are essentially
the same for the services assigned to both APCs. Hence, the commenter
concluded that there is no basis for the differences in calculated
costs for the services under the OPPS and recommended that CMS study
this differential to provide insight into situations where the OPPS CCR
methodology to calculate costs does not result in an accurate measure
of relative resource utilization.
Response: We agree that it appears that the resources required to
perform the vascular ultrasound and echocardiography services in these
APCs appear, from a clinical perspective, to be very similar. We
performed a limited initial examination of elements of the CY 2006
claims data for these APCs to determine if we could identify the reason
for the difference in estimated median costs. We first looked at the
charges for the services in these APCs, because one of the most
fundamental elements of the calculation of estimated costs is
hospitals'' charges for the services. The mean charge per service for
the 17 HCPCS codes assigned to APC 0267 was approximately $786. In
contrast, the mean charge per service for the three procedure codes
assigned to APC 0269 was approximately $1,135. Clearly, on average
hospitals charge much more for the services in APC 0269 than for the
services in APC 0267. However, while the proposed payment for APC 0267
was 38 percent of the proposed payment for APC 0269, the mean charge
for APC 0267 based upon the final rule data was 64 percent of the mean
charge for APC 0269. Therefore, there is more of a disparity between
the payments (and hence, between the median costs) than between the
mean charges.
We next looked at the total frequency of services furnished in each
APC and found that the total frequency of services was quite
substantial in each APC. Therefore, it is unlikely that the disparity
between the median costs for the two APCs is related to differences in
[[Page 66728]]
total volumes of services residing in those APCs. APC 0267 had a total
frequency of approximately 1.2 million claims and APC 0269 had a total
frequency of approximately 1 million claims in the final rule data from
CY 2006 claims.
We then looked at single bills as a percentage of the total
frequency and found that there is good representation in the single
bills. For APC 0267, we were able to use approximately 99 percent of
the total claims to set the median cost and for APC 0269, we were able
to use approximately 75 percent of the total claims to set the median
cost. Hence, the disparity is unlikely to be related to the variability
associated with using a small percentage of total claims to calculate
the median costs.
We also looked at the number of providers that furnish the highest
volumes of services in each APC to see if there were significantly
different counts of providers that might be a factor in the differences
in estimated costs. CPT code 93880 (Duplex scan of intracranial
arteries; complete bilateral study), assigned to APC 0267, was
furnished by 3,119 hospitals and CPT code 93970 (Duplex scan of
extremity veins including responses to compression and other maneuvers,
complete bilateral study) was furnished by 3,160 hospitals in CY 2006.
Similarly, CPT code 93307 (Echocardiography, transthoracic, real-time
with imaging documentation (2D) with or without M-mode recording;
complete), assigned to APC 0269, was furnished by 3,227 hospitals in CY
2006. These are a large number of the 4,089 hospitals whose claims were
used for the final rule median cost calculations and, therefore, it is
unlikely that idiosyncratic data from a few providers could be causing
the disparity.
We note that the CY 2008 median cost of APC 0267 was about the same
as its CY 2007 median cost, whereas the median cost of APC 0269 was
almost double its CY 2007 median cost. We believe the increased cost of
APC 0269 for CY 2008 may be a result of the CY 2008 packaging approach
for ancillary and supportive services described in section II.A.4.c. of
this final rule with comment period. In particular, the packaging of
payment for doppler echocardiography and color flow velocity mapping,
which are frequently reported with the CPT codes assigned to APC 0269
and which have been paid separately under the OPPS prior to CY 2008,
may have contributed to the increased cost for APC 0269, whereas
services assigned to APC 0267 had little new packaging due to our CY
2008 packaging approach.
We note we wish to investigate further the specific packaging
associated with services assigned to both APCs, the revenue codes under
which the services were charged, the revenue centers to which these
revenue codes mapped, and the CCRs that applied to the charges for
these services. We intend to undertake this further analysis and to
discuss our findings with the APC Panel at its winter 2008 meeting.
However, for CY 2008 we are basing payment for APCs 0267 and 0269
on the median costs calculated from our claims data according to our
standard median cost calculation process because our investigation of
the data does not reveal a problem with the methodology or with the
data. At this point, it appears that the median costs may be different
because of dissimilar packaging and because hospitals charge
significantly less for the services in APC 0267 than they charge for
the services in APC 0269, where this significant difference in charges
is not neutralized by the application of the CCRs applicable to these
charges. Therefore, the median cost for APC 0267 is significantly lower
than the median cost for APC 0269.
After consideration of the public comment received, we are
finalizing our CY 2008 proposal, without modification, to provide
payment for APCs 0267 and 0269 based on costs from claims, according to
the standard OPPS methodology, with median costs of approximately $150
and $404, respectively. We note that for CY 2008, APC 0269 will be paid
specifically for noncontrast echocardiography studies. We plan to
analyze these APCs further and discuss our findings with the APC Panel
at its winter 2008 meeting.
9. Other Procedures
a. 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, 2006, and
2007. For CY 2008, we proposed to continue using the same methodology
to estimate a ``per unit'' median cost for HCPCS code C1300 of
approximately $99 using 60,775 claims with multiple units or multiple
occurrences for the proposed rule.
CY 2008 is the fourth year in which we will have 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 4 years. As stated in the proposed rule (72 FR 42706), we believe
that this adjustment through use of the hospitals' overall CCRs is all
that is necessary to yield a
[[Page 66729]]
valid median cost for establishing a scaled weight for HBOT services.
Therefore, for CY 2008, we proposed to continue to use the same
methodology that we have used since CY 2005 to estimate payment for
HBOT.
We received one public comment on our proposal. A summary of the
public comment and our response follow.
Comment: One commenter commended CMS for applying a consistent
methodology of utilizing an overall hospital CCR to yield a valid
median cost for HBOT services. However, the commenter also encouraged
CMS to consider an alternative methodology for calculating a median
cost for HBOT. Specifically, the commenter stated that a contractor for
a wound care association had established and reproduced an accurate CCR
for HBOT and encouraged CMS to consider this methodology for the near
future.
Response: We appreciate the commenter's support for our proposed
methodology for estimating a ``per unit'' median cost for HBOT. In
response to the comment urging us to utilize an alternate calculation
to estimate a median cost for HBOT services, we note, as we did in our
CY 2005 OPPS final rule with comment period (69 FR 65759), that we are
not confident that the external research produces a definitive CCR for
HBOT. That final rule with comment period provided an extensive
discussion of our concerns about using survey findings to set, rather
than validate, APC medians. These concerns included a lack of
subscripted cost centers in the electronic cost report database, the
wide variability in observed CCRs, and the possibility of nonresponse
bias. As also noted in the CY 2005 final rule with comment period, we
agree that the previous study definitively demonstrated great diversity
among hospitals in the subscripted location of reported hyperbaric
oxygen costs on the cost report, which prompted us to use the
hospital's overall CCR, rather than a specific cost center CCR that
would be used in our standard ratesetting methodology. We continue to
believe that the median cost for APC 0659 developed according to our
established ``per unit'' median cost calculation for HBOT is an
appropriate relative cost to be used to set the payment weight upon
which the HBOT payment is based.
After consideration of the public comment received, we are
finalizing our CY 2008 proposal, without modification, for estimating a
``per unit'' median cost for HCPCS code C1300, assigned to APC 0659,
with a median cost of approximately $98 based on 67,435 claims with
multiple units or multiple occurrences.
b. Skin Repair Procedures (APCs 0133, 0134, 0135, 0136, and 0137)
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.
Specifically, the section of the CPT book previously titled ``Free Skin
Grafts'' and containing codes for skin repair 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, 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, 37 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 OPPS final rule with comment period and were
subject to comment.
In considering the final CY 2007 APC assignments of these 37 ``Skin
Replacement Surgery and Skin Repair'' codes, we reviewed the
recommendations made by the APC Panel at its March 2006 meeting;
presentations made to the APC Panel; comments received on the CY 2007
proposed rule; the CPT code descriptors, introductory explanations,
cross-references, and parenthetical notes; the clinical characteristics
of the procedures; and the code-specific median costs for all related
CPT codes available from our CY 2005 claims data. A discussion of the
final CY 2007 APC assignments of these procedures can be found in the
CY 2007 OPPS/ASC final rule with comment period (71 FR 68054 through
68057).
In the CY 2008 OPPS/ASC proposed rule, we observed that we now have
CY 2006 data for the surgical procedures assigned to the 4 CY 2007 skin
repair APCs, including the 37 codes considered last year that were new
for CY 2006. The CY 2007 skin repair APCs are: APC 0024 (Level I Skin
Repair); APC 0025 (Level II Skin Repair); APC 0686 (Level III Skin
Repair); and APC 0027 (Level IV Skin Repair). Based on CY 2006 data
available for the proposed rule, the median costs for the APCs as
configured for CY 2007 were approximately: $93 for APC 0024; $251 for
APC 0025; $1,027 for APC 0686; and $1,340 for APC 0027. Both APCs 0024
and 0025 had 2 times violations based on CY 2006 claims data. The
HCPCS-specific median costs of significant procedures in APC 0024
ranged from approximately $83 to $255. We noted that a number of the
procedures currently assigned to APC 0024 were very low volume, with
few single claims available for ratesetting. Similarly, the median
costs of the significant procedures in APC 0025 ranged from a low of
about $119 to a high of about $399. This APC also contained a number of
low volume procedures, as well as some new CY 2007 CPT codes without CY
2006 claims data. There was also some variation in the median costs of
the HCPCS codes assigned to APCs 0686 and 0027, but there were no 2
times violations in these two APCs.
At the March 2007 APC Panel meeting, we discussed with the APC
Panel one possible reconfiguration of the skin repair APCs in order to
address the 2 times violations in APCs 0024 and 0025 for CY 2008 by
improving the resource homogeneity of the APCs, as well as ensuring
their clinical homogeneity. We reviewed with the APC Panel the
potential results associated with adding an additional level in this
APC series and reallocating all of the procedures in the original four
APCs among five new APCs, taking into account the frequency, resource
utilization, and clinical characteristics of each procedure. We also
gave particular attention to CPT code families in considering the
clinical and resource homogeneity of each APC in the reconfigured
series. The new configuration of APCs eliminated the 2 times violations
that would have otherwise existed in APCs 0024 and 0025. It also more
accurately attributed higher cost procedures to the Levels IV and V
APCs, which contain the surgical procedures of the greatest intensity
and resource requirements, leading to a more balanced distribution of
APC median costs across the five new APC levels.
The APC Panel made a recommendation at its March 2007 meeting
supporting the reorganization by CMS of the skin repair APCs into five
levels. This recommendation also asked CMS to give special
consideration to the
[[Page 66730]]
APC assignments of ``add-on'' codes; in the context of skin procedures,
these are generally those CPT codes that report treatment of an
additional body area and that are reported along with a primary
procedure for treatment of the first body area. In the proposed rule
(72 FR 42707), we stated that we accepted the APC Panel's
recommendation through this CY 2008 proposal to reconfigure the skin
APCs into five levels, and we reexamined the placement of each of the
add-on codes within the framework of the five APCs. We agreed with the
APC Panel that, because these skin repair APCs were assigned to status
indicator ``T'' so that add-on codes would typically be paid at 50
percent of their APC payment rate, these add-on codes warranted special
examination with respect to their median costs and their appropriate
APC assignments. As a result, several CPT code placements from the
draft configuration discussed with the APC Panel were changed for the
CY 2008 proposal.
In summary, for CY 2008 we proposed to eliminate the four CY 2007
skin repair APCs and replace them with five new APCs titled: APC 0133
(Level I Skin Repair); APC 0134 (Level II Skin Repair); APC 0135 (Level
III Skin Repair); APC 0136 (Level IV Skin Repair); and APC 0137 (Level
V Skin Repair). We proposed to redistribute each of the procedures
assigned to the current four levels of skin repair APCs into the five
proposed APCs, with one exception. Specifically, we proposed to
reassign CPT code 15835 (Excision, excessive skin and subcutaneous
tissue (including lipectomy); buttock) to APC 0022 (Level IV, Excision/
Biopsy), where other CPT codes in its code family reside. The median
costs of the five proposed APCs were approximately $84 (APC 0133); $133
(APC 0134); $295 (APC 0135); $971 (APC 0136); and $1,317 (APC 0137).
The proposed configurations of these new APCs were listed in Table 30
of the proposed rule.
At the September 2007 meeting of the APC Panel, one presenter
requested that CPT codes 15340 (Tissue cultured allogeneic skin
substitute; first 25 sq cm or less) and 15341 (Tissue cultured
allogeneic skin substitute; each additional 25 sq cm) be moved from the
proposed APC 0134 (Level II Skin Repair) to APC 0135 (Level III Skin
Repair). The presenter stated that the CY 2008 proposal to reassign the
CPT codes for the application of certain skin products to different
APCs is premature because hospitals have been confused by the CY 2006
code descriptor changes made by the CPT Editorial Panel. Current CPT
instructions state that hospitals should not bill these two procedures
in conjunction with the CPT codes for wound site preparation and
debridement (CPT codes 15002-15005). The presenter stated that the CMS
data used in the proposed rule do not reflect the true costs of
performing CPT codes 15340 or 15341 because hospitals have been slow to
adjust their charges based on the coding changes. The APC Panel made no
recommendation at the September 2007 meeting related to the presenter's
recommendations or to the overall skin repair APC proposal.
We received numerous public comments concerning our CY 2008
proposals for these skin repair procedures. A summary of the public
comments and our responses follow.
Comment: Many commenters provided recommendations regarding the CY
2008 proposed treatment of specific skin repair CPT codes. One
commenter suggested delaying the proposed reconfiguration from four
skin repair APCs to five. Many commenters submitted similar letters
requesting that CPT codes 15340 and 15341 be moved from the proposed
APC 0134 to APC 0135, expressing concern that their placement in
proposed APC 0134 did not reflect the actual clinical resource use for
the application of the single skin repair biological product currently
described by HCPCS code J7340 (Dermal and epidermal, (substitute)
tissue of human origin, with or without bioengineered or processed
elements, per square centimeter) because hospitals have been confused
about appropriate billing for these surgical procedures. The commenters
expressed concern that the proposed changes to the skin repair APCs
would negatively impact patient access to skin repair procedures, such
as CPT codes 15340 and 15341.
One commenter believed that the proposed payments for the proposed
five level APC series would create an inappropriate incentive to use
specific competing skin replacement and skin substitute products,
because in many cases different biologicals used for skin repair are
reported with different CPT codes that were, in turn, proposed for
assignment to various APC levels. The commenter requested that CMS move
CPT codes 15340 and 15341 from the proposed APC 0134 to APC 0135 in
order to treat the application of J7340 similarly to other skin repair
procedures and to recognize the facility costs associated with wound
site preparation for J7340. Alternatively, the commenter recommended
that CMS delay restructuring the four CY 2007 APCs and except APCs 0024
and 0025 (based on their CY 2007 structure) from the 2 times rule until
another year of claims data are available for the CPT codes that were
new in CY 2006. As a third alternative, the commenter suggested
assigning all 16 skin repair CPT codes discussed by the APC Panel last
year to a new and separate APC. (A complete listing and discussion of
the codes and recommendations of the APC Panel for CY 2007 may be found
in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68054
through 68057).) Finally, the commenter requested that CMS depart from
CPT billing guidance and allow hospitals to report CPT codes for wound
site preparation, such as CPT code 15002 (Surgical preparation or
creation of recipient site by excision of open wounds, burn eschar, or
scar (including subcutaneous tissues), or incisional release of scar
contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of
infants and children), or create a new Level II HCPCS G-code, mapped
APC 0135, to be used by hospitals to specifically report site
preparation performed in conjunction with application of tissue
cultured allogeneic skin substitutes described by HPCS code J7340.
A few commenters also requested that the CPT skin repair codes
related to application of the single skin repair biological product
currently described by HCPCS code J7342 (Dermal (substitute) tissue of
human origin, with or without other bioengineered or processed
elements, with metabolically active elements, per square centimeter),
specifically 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 1% of
body area of infants and children) and 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 1% of body area of infants and children; each additional
100 sq cm, or each additional 1% of body area of infants and children,
or part thereof (List separately in addition to code for primary
procedure)) be moved from the proposed APC 0134 to APC 0135. The
commenters stated that the storage and handling of the product applied
with these CPT codes is more resource-intensive than other products
whose application procedures were proposed for assignment to APC 0135.
They also explained that the claims data that CMS used for APC
placement do not accurately reflect the costs associated with these
procedures because the product was not available on the market from CY
2006 through the beginning of CY 2007. In addition, they argued that
[[Page 66731]]
hospital confusion about skin repair CPT coding changes has led to
inaccurate claims.
Response: We have examined CY 2006 claims data available for the CY
2008 final rule with comment period, as well as each of the comments
and the public presentation from the September 2007 APC Panel meeting,
and find that the five level APC configuration we proposed most
appropriately allocates the large number of skin repair and replacement
procedures based on the frequency, resource utilization, and clinical
characteristics of each procedure. The proposed configuration
eliminates the 2 times violations in APCs 0024 and 0025 that would
otherwise exist and more accurately attributes higher cost procedure
codes to the proposed Levels IV and V APCs.
As for the specific CPT code assignments raised by commenters (CPT
codes 15340/15341 and 15365/15366), these codes were all placed in the
Level II Skin Repair APC for CY 2007 and were proposed to remain in the
Level II Skin Repair APC for CY 2008. In addition to these codes, the
following skin repair codes that were new for CY 2006 and discussed by
the APC Panel in CY 2006 were also proposed to be assigned to proposed
new APC 0134: CPT codes 15170 (Acellular dermal replacement, truck,
arms, legs; first 100 sq cm or less, or 1% of body area of infants and
children); CPT code 15171 (Acellular dermal replacement, truck, arms,
legs; first 100 sq cm or less, or 1% of body area of infants and
children; each additional 100 sq cm, or each additional 1% of body area
of infants and children, or part thereof (List separately in addition
to code for primary procedure)); CPT code 15360 (Tissue cultured
allogeneic dermal substitute, trunk, arms, legs; first 100 sq cm or
less, or 1% of body area of infants and children): and CPT code 15361
(Tissue cultured allogeneic dermal substitute, trunk, arms, legs; first
100 sq cm or less, or 1% of body area of infants and children; each
additional 100 sq cm, or each additional 1% of body area of infants and
children, or part thereof (List separately in addition to code for
primary procedure). Therefore, we disagree with commenters who believe
that we have not treated CPT codes 15340, 15341, 15365 and 15366
similarly to other skin repair procedures. The other 10 skin repair and
replacement codes proposed for assignment to APC 0135 have
significantly higher median costs than the CPT codes discussed by the
commenters. We note, in particular, that payment for HCPCS code J7341
(dermal (substitute) tissue of non-human origin, with or without other
bioengineered or processed with metabolically active elements, per
square centimeter) whose is application is reported with CPT codes
15430 (Acellular xenograft implant; first 100 sq cm or less, or 1% of
body area of infants and children) and 15431 (Acellular xenograft
implant; first 100 sq cm or less, or 1% of body area of infants and
children; each additional 100 sq cm, or each additional 1% of body area
of infants and children, or part thereof (List separately in addition
to code for primary procedure)), is packaged for CY 2008 because the
mean per day cost of J7341 is less than the final $60 drug packaging
threshold. Therefore, it is not surprising that these two CPT codes
have higher median costs than CPT codes 15340, 15341, 15365 and 15366
and were proposed for assignment to the higher paying Level III APC
0135, rather than to APC 0134.
Further, we do not believe that it would be appropriate to maintain
our CY 2007 structure for the skin repair APCs because we have
significant claims data for the new CY 2006 CPT codes that capture the
differential hospital costs associated with the procedures. We have no
reason to except two of the four skin repair APCs from the 2 times rule
based on their CY 2007 structure when the five level configuration that
we proposed and that was supported by the APC Panel demonstrates
clinical and resource homogeneity without 2 times violations. In
particular, we have over 8,000 single claims for CPT code 15340, so we
are confident that the procedure's final median cost of approximately
$162 falls within the range of costs for other procedures also assigned
to APC 0134, and the APC's median cost of approximately $132.
Similarly, CPT code 15341 for the application of each additional area
has a median cost of approximately $100, so it would be appropriately
paid based on the 50 percent multiple procedure reduction applicable to
APC 0134. Likewise, we have almost 200 claims for CPT code 15365 from
CY 2006, with a median cost of approximately $147 that is consistent
with the median costs of other procedures also assigned to APC 0134. We
note one commenter requested that we provide higher payment for CPT
codes 15365 and 15366 to apply J7342 because of the greater handling
and storage costs of the particular biological. However, we pay for
such pharmacy overhead through payment for the biological, not the
associated procedures, because, as we describe in section V.B. of this
final rule with comment period, we believe that hospitals include the
costs of pharmacy overhead in their charges for drugs and biologicals.
Despite the commenter's concern about the integrity of the data because
it reported that there was limited availability of the biological
described by HCPCS code J7342 in CY 2006, our CY 2006 claims data
include over 25,000 units of the product provided on almost 1,200 days
of service under the OPPS. In summary, we are confident that our CY
2006 claims data for the procedures reported with CPT codes 15340,
15341, 15365, and 15365 accurately reflect the hospital costs of those
procedures and that their proposed APC assignments are appropriate. We
note that HCPCS codes J7340 and J7342 for the associated biologicals
will be separately paid under the CY 2008 OPPS at ASP+5 percent, as
discussed in section V.B.3. of this final rule with comment period.
We do not move CPT codes to higher paying APCs in anticipation of
future changes in hospital billing practices, so we believe that it
would be premature to reassign any of the four procedures of particular
interest to commenters to APC 0135 and unnecessary to create a sixth
APC specifically for the 16 skin substitute and skin replacement codes
mentioned by the commenter. We also believe that it would be
inappropriate in this case to depart from CPT instructions by allowing
hospitals to separately report wound site preparation and debridement
when services described by CPT codes 15340 and 15341 are performed,
whether using the associated CPT codes or by creating a G code. We
generally advise hospitals to follow CPT billing guidance, and we
disagree with the commenter that the CPT guidance does not adequately
reflect the hospital facility component of these services. CPT coding
instructions package the wound site preparation into the two codes for
application of the biological, and hospitals have been reporting the
services since CY 2006 based on those CPT instructions. Given our
commitment to greater packaging under the OPPS, it would be
inconsistent to adopt a policy for payment of these skin repair
procedures that would move away from encounter-based payment by
unpackaging wound site preparation.
After consideration of the public comments received, we are
finalizing our CY 2008 proposed reconfiguration of the skin substitute
and skin replacement APCs, without modification, as shown in Table 22
below.
[[Page 66732]]
Table 22.--CY 2008 Skin Repair APC Configuration
------------------------------------------------------------------------
CY 2008 APC
HCPCS code Short descriptor CY 2008 APC median
cost
------------------------------------------------------------------------
11950.............. Therapy for contour 0133 $80
defects.
11951.............. Therapy for contour
defects.
11952.............. Therapy for contour
defects.
11954.............. Therapy for contour
defects.
12001.............. Repair superficial
wound(s).
12002.............. Repair superficial
wound(s).
12004.............. Repair superficial
wound(s).
12005.............. Repair superficial
wound(s).
12006.............. Repair superficial
wound(s).
12007.............. Repair superficial
wound(s).
12011.............. Repair superficial
wound(s).
12013.............. Repair superficial
wound(s).
12014.............. Repair superficial
wound(s).
12015.............. Repair superficial
wound(s).
12016.............. Repair superficial
wound(s).
12017.............. Repair superficial
wound(s).
12018.............. Repair superficial
wound(s).
12031.............. Layer closure of wound(s)
12041.............. Layer closure of wound(s)
12051.............. Layer closure of wound(s)
12052.............. Layer closure of wound(s)
12053.............. Layer closure of wound(s)
15775.............. Hair transplant punch
grafts.
15776.............. Hair transplant punch
grafts.
11760.............. Repair of nail bed....... 0134 132
11920.............. Correct skin color
defects.
11921.............. Correct skin color
defects.
11922.............. Correct skin color
defects.
12032.............. Layer closure of wound(s)
12034.............. Layer closure of wound(s)
12035.............. Layer closure of wound(s)
12036.............. Layer closure of wound(s)
12037.............. Layer closure of wound(s)
12042.............. Layer closure of wound(s)
12044.............. Layer closure of wound(s)
12045.............. Layer closure of wound(s)
12046.............. Layer closure of wound(s)
12047.............. Layer closure of wound(s)
12054.............. Layer closure of wound(s)
12055.............. Layer closure of wound(s)
12056.............. Layer closure of wound(s)
12057.............. Layer closure of wound(s)
13120.............. Repair of wound or lesion
13122.............. Repair wound/lesion add-
on.
13153.............. Repair wound/lesion add-
on.
15040.............. Harvest cultured skin
graft.
15170.............. Acell graft trunk/arms/
legs.
15171.............. Acell graft t/arm/leg add-
on.
15340.............. Apply cult skin
substitute.
15341.............. Apply cult skin sub add-
on.
15360.............. Apply cult derm sub, t/a/
l.
15361.............. Aply cult derm sub t/a/l
add.
15365.............. Apply cult derm sub f/n/
hf/g.
15366.............. Apply cult derm f/hf/g
add.
15819.............. Plastic surgery, neck....
12020.............. Closure of split wound... 0135 285
12021.............. Closure of split wound...
13100.............. Repair of wound or lesion
13101.............. Repair of wound or lesion
13102.............. Repair wound/lesion add-
on.
13121.............. Repair of wound or lesion
13131.............. Repair of wound or lesion
13132.............. Repair of wound or lesion
13133.............. Repair wound/lesion add-
on.
13150.............. Repair of wound or lesion
13151.............. Repair of wound or lesion
13152.............. Repair of wound or lesion
15000.............. Wound prep, 1st 100 sq cm
15001.............. Wound prep, addl 100 sq
cm.
15002.............. Wnd prep, ch/inf, trk/arm/
lg.
[[Page 66733]]
15003.............. Wnd prep, ch/inf addl 100
cm.
15004.............. Wnd prep ch/inf, f/n/hf/g
15005.............. Wnd prep, f/n/hf/g, addl
cm.
15050.............. Skin pinch graft.........
15110.............. Epidrm autogrft trnk/arm/
leg.
15111.............. Epidrm autogrft t/a/l add-
on.
15115.............. Epidrm a-grft face/nck/hf/
g.
15116.............. Epidrm a-grft f/n/hf/g
addl.
15150.............. Cult epiderm grft t/arm/
leg.
15151.............. Cult epiderm grft t/a/l
addl.
15152.............. Cult epiderm graft t/a/l
+%.
15155.............. Cult epiderm graft, f/n/
hf/g.
15156.............. Cult epidrm grft f/n/hfg
add.
15157.............. Cult epiderm grft f/n/hfg
+%.
15175.............. Acellular graft, f/n/hf/g
15176.............. Acell graft, f/n/hf/g add-
on.
15221.............. Skin full graft add-on...
15241.............. Skin full graft add-on...
15300.............. Apply skinallogrft, t/arm/
lg.
15301.............. Apply sknallogrft t/a/l
addl.
15320.............. Apply skin allogrft f/n/
hf/g.
15321.............. Aply sknallogrft f/n/hfg
add.
15330.............. Aply acell alogrft t/arm/
leg.
15331.............. Aply acell grft t/a/l add-
on.
15335.............. Apply acell graft, f/n/hf/
g.
15336.............. Aply acell grft f/n/hf/g
add.
15350.............. Skin homograft...........
15351.............. Skin homograft add-on....
15400.............. Apply skin xenograft, t/a/
l.
15401.............. Apply skn xenogrft t/a/l
add.
15420.............. Apply skin xgraft, f/n/hf/
g.
15421.............. Apply skn xgrft f/n/hf/g
add.
15430.............. Apply acellular xenograft
15431.............. Apply acellular xgraft
add.
20926.............. Removal of tissue for
graft.
43887.............. Remove gastric port, open
11762.............. Reconstruction of nail 0136 947
bed.
14000.............. Skin tissue rearrangement
14001.............. Skin tissue rearrangement
14020.............. Skin tissue rearrangement
14021.............. Skin tissue rearrangement
14040.............. Skin tissue rearrangement
14041.............. Skin tissue rearrangement
14060.............. Skin tissue rearrangement
14061.............. Skin tissue rearrangement
15130.............. Derm autograft, trnk/arm/
leg.
15131.............. Derm autograft t/a/l add-
on.
15135.............. Derm autograft face/nck/
hf/g.
15136.............. Derm autograft, f/n/hf/g
add.
15200.............. Skin full graft, trunk...
15201.............. Skin full graft trunk add-
on.
15220.............. Skin full graft sclp/arm/
leg.
15240.............. Skin full grft face/genit/
hf.
15260.............. Skin full graft een &
lips.
15261.............. Skin full graft add-on...
15740.............. Island pedicle flap graft
15936.............. Remove sacrum pressure
sore.
15952.............. Remove thigh pressure
sore.
15953.............. Remove thigh pressure
sore.
15956.............. Remove thigh pressure
sore.
15958.............. Remove thigh pressure
sore.
20920.............. Removal of fascia for
graft.
20922.............. Removal of fascia for
graft.
23921.............. Amputation follow-up
surgery.
25929.............. Amputation follow-up
surgery.
33222.............. Revise pocket, pacemaker.
33223.............. Revise pocket, pacing-
defib.
11960.............. Insert tissue expander(s) 0137 1,271
13160.............. Late closure of wound....
14300.............. Skin tissue rearrangement
[[Page 66734]]
14350.............. Skin tissue rearrangement
15100.............. Skin splt grft, trnk/arm/
leg.
15101.............. Skin splt grft t/a/l, add-
on.
15120.............. Skn splt a-grft fac/nck/
hf/g.
15121.............. Skn splt a-grft f/n/hf/g
add.
15570.............. Form skin pedicle flap...
15572.............. Form skin pedicle flap...
15574.............. Form skin pedicle flap...
15576.............. Form skin pedicle flap...
15600.............. Skin graft...............
15610.............. Skin graft...............
15620.............. Skin graft...............
15630.............. Skin graft...............
15650.............. Transfer skin pedicle
flap.
15731.............. Forehead flap w/vasc
pedicle.
15732.............. Muscle-skin graft, head/
neck.
15734.............. Muscle-skin graft, trunk.
15736.............. Muscle-skin graft, arm...
15738.............. Muscle-skin graft, leg...
15750.............. Neurovascular pedicle
graft.
15760.............. Composite skin graft.....
15770.............. Derma-fat-fascia graft...
15820.............. Revision of lower eyelid.
15821.............. Revision of lower eyelid.
15822.............. Revision of upper eyelid.
15823.............. Revision of upper eyelid.
15824.............. Removal of forehead
wrinkles.
15825.............. Removal of neck wrinkles.
15826.............. Removal of brow wrinkles.
15828.............. Removal of face wrinkles.
15829.............. Removal of skin wrinkles.
15840.............. Graft for face nerve
palsy.
15841.............. Graft for face nerve
palsy.
15842.............. Flap for face nerve palsy
15845.............. Skin and muscle repair,
face.
15876.............. Suction assisted
lipectomy.
15877.............. Suction assisted
lipectomy.
15878.............. Suction assisted
lipectomy.
15879.............. Suction assisted
lipectomy.
15922.............. Removal of tail bone
ulcer.
15934.............. Remove sacrum pressure
sore.
15935.............. Remove sacrum pressure
sore.
15937.............. Remove sacrum pressure
sore.
15944.............. Remove hip pressure sore.
15945.............. Remove hip pressure sore.
15946.............. Remove hip pressure sore.
20101.............. Explore wound, chest.....
20102.............. Explore wound, abdomen...
20910.............. Remove cartilage for
graft.
20912.............. Remove cartilage for
graft.
43886.............. Revise gastric port, open
43888.............. Change gastric port, open
44312.............. Revision of ileostomy....
44340.............. Revision of colostomy....
------------------------------------------------------------------------
c. Stereotactic Radiosurgery (SRS) Treatment Delivery Services (APCs
0065, 0066, and 0067)
For CY 2007, the CPT Editorial Panel created four new SRS Category
I CPT codes in the Radiation Oncology 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).
Of the four CPT codes, CPT codes 77371 and 77435 were recognized
under the OPPS effective January 1, 2007, while CPT codes 77372 and
77373 were not. CPT code 77371 was assigned to the same APC and status
indicator as its
[[Page 66735]]
predecessor code, HCPCS code G0243 (Multi-source photon stereotactic
radiosurgery, delivery including collimator changes and custom
plugging, complete course of treatment, all lesions). For CY 2007, CPT
code 77371 was assigned to APC 0127 (Level IV Stereostatic
Radiosurgery) with a status indicator of ``S.'' Prior to CY 2007, CPT
code 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 decided
to delete CPT code 0083T on December 31, 2006, and replaced it with CPT
code 77435. Because the costs of SRS treatment management were already
packaged into the OPPS payment rates for SRS treatment delivery, we
assigned CPT code 77435 to status indicator ``N'' which was the same
status indicator that was assigned to its predecessor Category III CPT
code (0083T), under the OPPS, effective January 1, 2007. In the CY 2008
OPPS/ASC proposed rule (72 FR 42716), we noted that the OPPS treatment
of these new CPT codes was open to comment in the CY 2007 OPPS/ASC
final rule with comment period, and indicated that we would
specifically respond to those comments, according to our usual
practice, in this final rule with comment period.
As we explained in the CY 2007 OPPS/ASC final rule with comment
period (71 FR 68025), we did not recognize CPT codes 77372 and 77373
because they did not accurately and specifically describe the HCPCS G-
codes that we used in prior years for linear accelerator (LINAC)-based
SRS treatment delivery services under the OPPS. During CY 2006, CPT
code 77372 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
were more specific in their descriptors than CPT code 77372, we decided
to continue using HCPCS codes G0173 and G0339 under the OPPS for CY
2007. For CY 2007, we assigned CPT code 77372 status indicator ``B''
under the OPPS. In addition, 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 were more
specific in their descriptors than CPT code 77373 and were also
assigned to different clinical APCs for CY 2007, we decided to continue
recognizing HCPCS codes G0251, G0339, and G0340 under the OPPS for CY
2007. Therefore, for CY 2007 we assigned CPT code 77373 status
indicator ``B'' under the OPPS.
In the CY 2008 proposed rule (72 FR 42716 through 42717), we
explained that while we had received requests from certain specialty
societies and other stakeholders that we recognize CPT codes 77372 and
77373 under the OPPS rather than continuing to use the current Level II
HCPCS codes for hospital outpatient facility reporting of these
procedures, we had also heard from others that continued use of the G-
codes under the OPPS would be the most appropriate way to recognize the
facility resource differences between different types of LINAC-based
procedures. For the past several years, we had collected information
through our claims data regarding the hospital costs associated with
the planning and delivery of SRS services. As new technology emerged in
the field of SRS several years ago, public commenters urged CMS 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. Based on comments received on the CY 2004
OPPS proposed rule regarding the G-codes used for SRS, we made some
modifications to the coding for CY 2004 (68 FR 63431 and 63432). First,
we received comments regarding the descriptors for HCPCS codes G0173
and G0251, indicating that these codes did not accurately 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 modified the
descriptor for G0173 and also created two HCPCS G-codes, G0339 and
G0340, to describe complete and fractionated image-guided robotic
linear accelerator-based SRS treatment. While all of these LINAC-based
SRS procedures were originally assigned to New Technology APCs under
the OPPS, we reassigned them to new clinical APCs for CY 2007 based on
2 full years of hospital claims data reflecting stable median costs
based on significant volumes of single claims.
HCPCS codes G0173, G0251, G0339, and G0340 are more specific in
their descriptors than either CPT code 77372 or 77373. As we discussed
in the CY 2008 proposed rule (72 FR 42717), their hospital claims data
continued to reflect significantly different hospital resources that
would lead to violations of the 2 times rule were we to reassign
certain procedures to the same clinical APCs in order to crosswalk the
CY 2006 historical claims data for the 4 G-codes to develop the median
costs of the APCs to which the 2 CPT codes would be assigned if we were
to recognize them. Therefore, we believed that we should continue to
use the G-codes for reporting LINAC-based SRS treatment delivery
services for CY 2008 under the OPPS to ensure appropriate payment to
hospitals for the different facility resources associated with
providing these complex services. That is, we proposed to continue to
assign HCPCS codes G0173 and G0339 to APC 0067 (Level III Stereotactic
Radiosurgery, MRgFUS, and MEG), HCPCS code G0251 to APC 0065 (Level I
Stereotactic Radiosurgery, MRgFUS, and MEG), and HCPCS code G0340 to
APC 0066 (Level II Stereotactic Radiosurgery, MRgFUS, and MEG) for CY
2008.
Since we first established the full group of SRS treatment delivery
codes in CY 2004, we note that we now have 3 years of hospital claims
data reflecting the costs of each of these services. Based on the
latest claims data from CY 2006 for the CY 2008 proposed rule, the
proposed APC median cost for the complete course of therapy in one
session or first fraction of image-guided, robotic LINAC-based SRS, as
described by HCPCS codes G0173 and G0339 respectively in APC 0067, was
approximately $3,870 based on 1,946 single claims available for
ratesetting. The proposed CY 2008 APC median cost for the second
through fifth sessions of image-guided, robotic LINAC-based
fractionated SRS treatment, reported by HCPCS code G0340 in APC 0066,
was approximately $2,980 based on 5,209 single claims. The proposed CY
2008 APC median cost for each fractionated
[[Page 66736]]
session of LINAC-based SRS, as described by HCPCS code G0251 in APC
0065, was approximately $1,082 based on 1,938 single claims. Therefore,
for CY 2008, we proposed to continue with the CY 2007 HCPCS coding for
LINAC-based SRS treatment delivery services under the OPPS. The LINAC
based SRS codes and their CY 2008 proposed APC assignments were
displayed in Table 36 of the proposed rule (72 FR 42717).
We received several public comments concerning our treatment of new
CPT codes for SRS treatment delivery discussed in the CY 2007 OPPS/ASC
final rule with comment period and our CY 2008 proposal for these
services. A summary of the public comments and our responses follow.
Comment: Several commenters agreed with CMS's proposed continued
use of HCPCS codes G0173, G0251, G0339, and G0340 to report SRS
services as these codes were more specific in their descriptors than
either CPT code 77372 or 77373. However, these commenters requested
that CMS further clarify the descriptors of these G-codes to more
specifically differentiate image-guided robotic SRS from other LINAC
systems. Other commenters to the CY 2008 proposed rule and the CY 2007
OPPS/ASC final rule with comment period disagreed with the use of the
G-codes and requested that CMS recognize the CPT codes for ease of
billing. Some commenters indicated that use of different codes for the
same service for different payers is not consistent with government and
industry goals for data uniformity and consistency, and is
administratively burdensome for hospitals. One commenter explained that
not all payers recognize Medicare's temporary HCPCS codes. This
commenter recommended that APCs 0065, 0066 and 0067 be combined into a
single APC containing the following codes: CPT codes 77372; 77373;
95966 (Magnetoencephalography (MEG), recording and analysis; for
spontaneous brain magnetic activity (e.g., epileptic cerebral cortex
localization)); 95967 (Magnetoencephalography (MEG), recording and
analysis; for evoked magnetic fields, single modality (e.g., sensory,
motor, language, or visual cortex localization)); 95965
(Magnetoencephalography (MEG), recording and analysis; for evoked
magnetic fields, each additional modality (e.g., sensory, motor,
language, or visual cortex localization) (List separately in addition
to code for primary procedure)); 0071T (Focused ultrasound ablation of
uterine leiomyomata, including MR guidance; total leiomyomata volume
less than 200 cc of tissue); and 0072T (Focused ultrasound ablation of
uterine leiomyomata, including MR guidance; total leiomyomata volume
greater or equal to 200 cc of tissue). Another commenter requested that
HCPCS code G0251 be reassigned from its proposed APC 0065 to APC 0067.
Additionally, several commenters disagreed with CMS's proposal to
assign both the MRgFUS and MEG procedures to APCs 0065, 0066, and 0067.
These commenters believed that MRgFUS and MEG procedures did not share
the same clinical or resource characteristics as SRS procedures. They
urged CMS to reassign the MRgFUS and MEG procedures to other APCs that
more accurately reflected their clinical characteristics and resource
use. Some commenters recommended that the MEG procedures be placed in
an APC that described nerve and muscle tests rather than assigning them
to an SRS APC. Other commenters did not understand why CMS included the
words ``MRgFUS'' and/or ``MEG'' in the APC titles for APCs 0065 and
0066 when the proposed APCs did not include one or both of these
procedures.
Response: We appreciate the various differences of opinion offered
by commenters on coding and payment for LINAC-based SRS treatment
delivery services under the OPPS. We will not recognize CPT codes 77372
and 77373 for CY 2008 because we continue to believe that they do not
accurately and specifically describe the HCPCS G-codes that we
currently use for reporting LINAC-based SRS treatment delivery services
under the OPPS. Hospital claims data from CY 2006 for the current G
codes demonstrate significant resource differences for the four
different services, ranging from approximately $994 to $3,620, and
these G-codes cannot be mapped in a one-to-one relationship to the CPT
codes. We remain unclear about how we could use our historical hospital
claims data as the basis for establishing appropriate payment rates for
CPT codes 77372 and 77373. We believe that our CY 2008 proposed APC
assignments for the four G-codes to APCs 0065, 0066, and 0067,
consistent with their CY 2007 assignments, will provide the most
appropriate payment for the SRS services described by these codes in CY
2008.
We note that we intend to reevaluate the appropriateness of the use
of the HCPCS G-codes for LINAC-based SRS services for the CY 2009 OPPS
rulemaking cycle. With that planned reevaluation in mind, we will not
modify the G-code descriptors for LINAC based SRS treatment services.
These codes have been in effect for the past 4 years and, based on
questions brought to our attention by hospitals, we have no reason to
believe that hospitals are confused about the reporting of these codes.
In addition, we see resource differences based on the median costs for
the four codes that are reasonably consistent with our expectations
based on the current code descriptors. We believe it would be confusing
to hospitals if we were to modify these code descriptors at this point
in time and could lead to instability in our median costs and
inaccurate payments for some services. Therefore, we believe that
modifying the G-code descriptors is not necessary for us to continue to
provide appropriate payment for the services they describe.
We disagree with the recommendation of some commenters to combine
all of the SRS, MEG, and MRgFUS procedures into one single clinical
APC, when the median costs for these services vary from approximately
$663 to $4,207. Such a single clinical APC would violate the 2 times
rule based on the different hospital resources required for all of the
services. With the respect to the proposed assignment of MEG and MRgFUS
services to APCs 0065 and 0067, we note that the APC Panel recommended
at its March 2007 meeting that we assign both CPT codes for MRgFUS
procedures to APC 0067. Although we have no single claims available for
CPT codes 0071T and 0072T for CY 2008 ratesetting, we continue to
believe that these services share sufficient clinical and resource
similarity to LINAC-based SRS procedures based on their use of image-
guidance and focused energy for tissue ablation that they should be
assigned to APC 0067 for CY 2008 as the APC Panel recommended and as we
proposed . With respect to MEG procedures, we also believe that, based
on the clinical characteristics of these services and the procedures'
median costs from claims data, these three services should also be
assigned to APCs 0065 and 0067 as proposed.
In the case of the APC titles for APCs 0065, 0066, and 0067,
because the titles specify three separate levels of the same series, we
will follow our usual practice of maintaining the same APC title for
each level for purposes of clarity and consistency, even if not all
specific services are assigned to every level.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to continue the
use of the current HCPCS G-codes for LINAC-based SRS treatment delivery
services, specifically, HCPCS G-codes G0173, G0251, G0339, and G0340,
under the
[[Page 66737]]
OPPS. We will not recognize CPT codes 77372 and 77373 under the CY 2008
OPPS. The HCPCS G-codes will continue to be assigned to the same CY
2007 APCs for CY 2008, specifically, APCs 0065, 0066, and 0067, with
final APC median costs of approximately $1,044, $2,835, and $3,882,
respectively. Table 23 displays the final APC median costs for the SRS
treatment delivery HCPCS G-codes.
Table 23.--Final CY 2008 APC Assignments for LINAC-Based SRS Treatment Delivery Services
----------------------------------------------------------------------------------------------------------------
CY 2007 Final CY
CY 2007 APC Final CY Final CY 2008 APC
HCPCS code Short descriptor CY 2007 SI APC median 2008 SI 2008 APC median
cost final cost
----------------------------------------------------------------------------------------------------------------
G0173............ Linear acc stereo S.......... 0067 $3,873 S.......... 0067 $3,882
radsur com.
G0251............ Linear acc based stero S.......... 0065 1,242 S.......... 0065 1,044
radio.
G0339............ Robot lin-radsurg com, S.......... 0067 3,873 S.......... 0067 3,882
first.
G0340............ Robt lin-radsurg fractx S.......... 0066 2,630 S.......... 0066 2,835
2-5.
----------------------------------------------------------------------------------------------------------------
10. Medical Services
a. 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 2008. Multiple allergy tests
are currently 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 2006 claims data available for the CY 2008 proposed
rule for APC 0381 (Single Allergy Tests) did not reflect improved and
more consistent hospital billing practices of ``per test'' for single
allergy tests. The median cost of APC 0381 calculated for the proposed
rule according to the standard single claims OPPS methodology was
approximately $66, significantly higher than the CY 2007 median cost of
APC 0381 calculated according to the ``per unit'' methodology of
approximately $16, and greater than we would expect for these
procedures that are to be reported ``per test'' with the appropriate
number of units. Some claims for single allergy tests still appeared to
provide charges that represent a ``per visit'' charge, rather than a
``per test'' charge. Therefore, consistent with our payment policy for
CYs 2006 and 2007, we calculated a ``per unit'' median cost for APC
0381, based upon 276 claims containing multiple units or multiple
occurrences of a single CPT code, where packaging on the claims is
allocated equally to each unit of the CPT code. Using this methodology,
we calculated a proposed median cost of approximately $19 for APC 0381
for CY 2008. We noted in the CY 2008 OPPS/ASC proposed rule (72 FR
42713) that we will consider whether further instructions to hospitals
for reporting these procedures would be beneficial, because we are
concerned that our claims data for CY 2006 reflect no apparent change
in hospitals' billing practices following our January 2006
clarification. We remain hopeful that better and more accurate hospital
reporting and charging practices for these single allergy test CPT
codes in future years may allow us to calculate the median cost of APC
0381 using the standard OPPS process for future OPPS updates.
We did not receive any public comments on this proposal. Therefore,
we are finalizing our CY 2008 proposal, without modification, to
calculate a ``per unit'' median cost for APC 0381 as described above.
The CY 2008 median cost of APC 0381 is approximately $17.
b. Continuous Glucose Monitoring (APC 0097)
For CY 2008, we proposed to reassign CPT code 95250 (Ambulatory
continuous glucose monitoring of interstitial fluid via a subcutaneous
sensor for up to 72 hours; sensor placement, hook-up; calibration of
monitor, patient training, removal of sensor, and printout of
recording) to APC 0097 (Prolonged Physiologic and Ambulatory
Monitoring), with a proposed payment rate of approximately $66. CPT
code 95250 is assigned to APC 0421 (Prolonged Physiologic Monitoring)
for CY 2007, with a payment rate of approximately $100. We also
proposed to discontinue APC 0421 effective January 1, 2008. At the
September 2007 APC Panel meeting, the APC Panel recommended that CMS
retain APC 0421 with its CY 2007 composition, including maintaining CPT
code 95250 in that APC for CY 2008.
We received one public comment on our CY 2008 proposed reassignment
of CPT code 95250 to APC 0097. A summary of the public comment and our
response follow.
Comment: One commenter considered the proposal to reassign CPT code
95250 to APC 0097 to be an apparent violation of the 2 times rule. The
commenter further reported that placement of CPT code 95250 in APC 0097
was problematic with respect to ensuring resource comparability among
all the procedures assigned to the APC for CY 2008, because continuous
glucose monitoring involves significant patient training of 30 to 40
minutes, whereas there is minimal to no patient training associated
with most of the other HCPCS codes in APC 0097. In addition, the
commenter noted that the OPPS payment for CPT code 95250 should include
payment for a sensor that costs approximately $35, which would consume
53 percent of the proposed payment for the service. The commenter
recommended that CMS not discontinue APC 0421 and maintain CPT code
95250 in APC 0421 for CY 2008. Alternatively, the commenter believed
that CMS could split APC 0097 into two APCs for Level I and Level II
services, assigning CPT code 95250 to the higher paying Level II APC.
Another commenter also recommended that CMS maintain APC 0421 on the
basis that the lower payment rate of APC 0097 would potentially result
in limiting patient access to this monitoring approach for patients
with diabetes.
Response: As described in section II.A.2. of this final rule with
comment period, for CY 2008 we proposed to eliminate many APCs with low
total claims volume in order to stabilize OPPS payments for these low
volume services. We generally proposed to reassign the services
residing in these low volume APCs to other clinical APCs, along with
services that share clinical and resource characteristics. We note that
APC 0421, as configured for
[[Page 66738]]
CY 2007 and where CPT code 95250 is currently assigned, is a low volume
APC, which would have included only about 750 CY 2006 claims. We
proposed to discontinue APC 0421 and reassign CPT code 95250 to APC
0097. Proposed APC 0097 consisted of 17 services, with approximately
487,000 CY 2006 claims for those services. Low volume services,
including CPT code 95250, are not significant services in APCs and,
therefore, do not result in violations of the 2 times rule.
We agree with the commenters that CPT code 95250 should not be
assigned to APC 0097, based on our review of its clinical and resource
characteristics. However, we will not maintain APC 0421 for CY 2008,
given our interest in eliminating low volume APCs, and, therefore, we
are not adopting the recommendation of the APC Panel. In addition, we
will not separate APC 0097 into two levels because we believe that an
alternative assignment of CPT code 95250 to another existing clinical
APC would be more appropriate. Taking into consideration the patient
training required in association with CPT code 95250, we believe that
it would be appropriate to assign this service to APC 0607 (Level 4
Hospital Clinic Visits), which has a CY 2008 final median cost of
approximately $104. The median cost of CPT code 95250 of approximately
$100 is well within the range of approximately $99 to $122 for other
significant procedures also assigned to that APC for CY 2008. This
final reassignment of CPT code 95250 to APC 0607 should resolve any
concerns about violations of the 2 times rule and leads to appropriate
grouping of the service with other similar services that share clinical
and resource characteristics.
After consideration of the public comment received, we are
finalizing our CY 2008 proposal with modification. We are discontinuing
APC 0421 and reassigning CPT code 95250 to APC 0607, with a CY 2008
median cost of approximately $104, rather than to APC 0097 as proposed.
c. Home International Normalized Ratio (INR) Monitoring (APC 0097)
For CY 2008, we proposed to reassign the two following HCPCS codes
to APC 0097 (Prolonged Physiologic and Ambulatory Monitoring), with a
proposed payment rate of approximately $66: G0248 (Demonstration at
initial use, of home INR monitoring for patient with mechanical heart
valve(s) who meets Medicare coverage criteria, under the direction of a
physician; includes: demonstrating use and care of the INR monitor,
obtaining at least one blood sample, provision of instructions for
reporting home INR test results, and documentation of patient ability
to perform testing) and HCPCS code G0249 (Provision of test materials
and equipment for home INR monitoring to patient with mechanical heart
valve(s) who meets Medicare coverage criteria; includes provision of
materials for use in the home and reporting of test results to
physician; per 4 tests). Currently, HCPCS codes G0248 and G0249 are
assigned to APC 0421 (Prolonged Physiologic Monitoring), with a payment
rate of approximately $100 for CY 2007. As stated in section
III.D.10.b. of this final rule with comment period, we also proposed to
discontinue APC 0421 effective January 1, 2008. At the September 2007
APC Panel meeting, the APC Panel recommended that CMS retain APC 0421
with its CY 2007 composition, including maintaining HCPCS codes G0248
and G0249 in that APC for CY 2008.
We received one public comment on our CY 2008 proposed reassignment
of HCPCS codes G0248 and G0249 to APC 0097. A summary of the public
comment and our response follow.
Comment: One commenter was concerned that CMS's proposal to
reassign HCPCS codes G0248 and G0249 from APC 0421 to APC 0097 would
substantially reduce payments for these services and would make it
financially impossible for hospitals to offer these services, thereby
reducing patient access to home INR monitoring. The commenter urged CMS
to maintain APC 0421 or, as an alternative, to create a new APC that
would include HCPCS codes G0248 and G0249 and two other higher cost
procedures also proposed for CY 2008 assignment to APC 0097,
specifically CPT code 93271 (Patient demand single or multiple event
recording with presymptom memory loop, 24-hour attended monitoring, per
30 day period of time; monitoring, receipt of transmissions, and
analysis) and CPT code 95250 (Ambulatory continuous glucose monitoring
of interstitial fluid via a subcutaneous sensor for up to 72 hours;
sensor placement, hook-up; calibration of monitor, patient training,
removal of sensor, and printout of recording).
Response: As described in section II.A.2. of this final rule with
comment period, for CY 2008 we proposed to eliminate many APCs with low
total claims volume in order to stabilize OPPS payments for these low
volume services. We generally proposed to reassign the services
residing in these low volume APCs to other clinical APCs, along with
services that share clinical and resource characteristics. We note that
APC 0421, as configured for CY 2007 and where HCPCS codes G0248 and
G0249 are currently assigned, is a low volume APC, which would have
included only about 750 CY 2006 claims. We proposed to discontinue APC
0421 and reassign HCPCS codes G0248 and G0249 to proposed APC 0097.
Proposed APC 0097 consisted of 17 services, with approximately 487,000
CY 2006 claims for those services.
We agree with the commenter that HCPCS codes G0248 and G0249 should
not be assigned to APC 0097, based on our reexamination of their
clinical and resource characteristics. However, we will not maintain
APC 0421 for CY 2008, given our interest in eliminating low volume
APCs, and, therefore, we are not adopting the recommendation of the APC
Panel. In addition, we will not create another new clinical APC
consisting of four of the higher cost services proposed for CY 2008
assignment to APC 0097 because we believe that alternative assignments
of those codes to other existing clinical APCs are more appropriate. We
discuss the final CY 2008 reassignment of CPT code 95250 to APC 0607
(Level 4 Hospital Clinic Visits) in section III.D.10.b. of this final
rule with comment period. In addition, we are reassigning CPT code
93271, which has a median cost of approximately $93 to APC 0663 (Level
I Electronic Analysis of Devices), with a CY 2008 median cost of
approximately $96. Taking into consideration the patient training
required in association with HCPCS code G0248 in particular, we believe
that it would be appropriate to assign both HCPCS codes G0248 and G0249
to APC 0607 (Level 4 Hospital Clinic Visits), which has a CY 2008 final
median cost of approximately $104. The median costs of HCPCS codes
G0248 and G0249 are approximately $72 and $120, respectively, similar
to the hospital costs for other services also assigned to that APC for
CY 2008.
After consideration of the public comment received, we are
finalizing our CY 2008 proposal, with modification. We are
discontinuing APC 0421 and reassigning HCPCS codes G0248 and G0249 to
APC 0607, with a CY 2008 median cost of approximately $104, rather than
to APC 0097 as proposed.
d. Mental Health Services (APCs 0322, 0323, 0324, and 0325)
For CY 2008, we did not propose any policy changes to the range or
composition of APCs that describe psychotherapy services provided in
HOPDs. These APCs include 0322 (Brief Individual Psychotherapy), which
has a CY 2008 median cost of approximately
[[Page 66739]]
$74; 0323 (Extended Individual Psychotherapy), which has a CY 2008
median cost of approximately $101; 0324 (Family Psychotherapy), which
has a CY 2008 median cost of approximately $149; and 0325 (Group
Psychotherapy), which has a CY 2008 median cost of approximately $62.
Proposals related to partial hospitalization programs are discussed in
section II.B. of this final rule with comment period.
We note that since the inception of the OPPS, CMS has limited the
aggregate payment for specified less intensive mental health services
furnished on the same date to the payment for a day of partial
hospitalization, which we considered to be the most intensive of all
outpatient mental health treatment (65 FR 18455). The costs associated
with administering a partial hospitalization program represent the most
resource-intensive of all outpatient mental health treatment, and we do
not believe that we should pay more for a day of individual mental
health services under the OPPS.
We received several public comments regarding our CY 2008 proposed
payment for APCs 0332, 0323, 0324, and 0325. A summary of the public
comments and our responses follow.
Comment: Several commenters noted that the payment rates associated
with APCs 0322, 0323, 0324, and 0325 have decreased in recent years.
Specifically, the commenters stated that payment associated with APC
0325 decreased by 17 percent between CY 2006 and CY 2007 and was
proposed to decline by an additional 3 percent for CY 2008. These
commenters expressed concern that the payment rates are insufficient to
cover their costs for mental health services. One commenter noted that
it is more cost-effective to treat Medicare beneficiaries in HOPDs,
rather than costly partial hospitalization programs, and encouraged CMS
to provide adequate payment rates to the less intensive programs.
Response: We carefully analyzed several years of resource cost data
associated with APCs 0322 through 0325. We note that the median costs
of APCs 0322, 0323, and 0324 have remained fairly constant in recent
years. APC 0323 has a small 2 times rule violation for CY 2008, and
also had a small violation in CY 2007, but it is not clear how to best
resolve the violation, while ensuring the clinical and resource
homogeneity of reconfigured APCs. For CY 2007 and CY 2008, APC 0323 is
excepted from the 2 times rule. We will review APC 0323 at the next APC
Panel meeting and seek its guidance in reconfiguring this APC for CY
2009. As the commenters noted, the median cost for APC 0325 declined
significantly in CY 2007, and declined again for CY 2008, using full
year CY 2006 claims data. We cannot speculate as to why this recent
decline in the median cost of group psychotherapy services has
occurred. We have robust claims data for the CPT codes that map to APC
0325. Specifically, we were able to use almost 80 percent of the 1.6
million claims submitted by hospitals to report group psychotherapy
services. In general, we set payment rates using our standard OPPS
methodology based on relative costs from hospital outpatient claims. In
this case, we have no reason to discount our claims data, and it would
appear that the relative cost of providing these mental health services
in comparison with other HOPD services has decreased in recent years.
While reviewing the CY 2008 OPPS proposal for mental health
services, we noted that CPT code 90862 (Pharmacologic management,
including prescription, use, and review of medication with no more than
minimal psychotherapy) and HCPCS code M0064 (Brief office visit for the
sole purpose of monitoring or changing drug prescriptions used in the
treatment of mental psychoneurotic and personality disorders) were
proposed to map to APC 0605 (Level 2 Hospital Clinic Visits) for CY
2008, with a proposed payment of approximately $64. These assignments
were proposed changes from their CY 2007 assignments to APC 0374
(Monitoring Psychiatric Drugs), which has a payment rate of
approximately $70. We proposed to discontinue APC 0374 for CY 2008.
Based on our reexamination of the claims data for this final rule with
comment period, particularly the hospitals costs associated with these
visits, we are reassigning HCPCS codes 90862 and M0064 to APC 0606
(Level 3 Hospital Clinic Visits) for CY 2008, with a median cost of
approximately $83.
Comment: Several commenters expressed concern that payment for
mental health services provided on one date is capped at the partial
hospitalization payment rate. One commenter noted that if an HOPD
provides four particular mental health services in one day, that
department would receive full payment for the first two services,
partial payment for the third service, and no payment for the fourth
service.
Response: We continue to believe that the costs associated with
administering a partial hospitalization program represent the most
resource intensive of all outpatient mental health treatment, and we do
not believe that we should pay more for a day of individual mental
health services under the OPPS. We note that these commenters also
submitted comments requesting that the partial hospitalization payment
rate increase for CY 2008. The mental health payment limitation will
rise and fall in the same manner as payment for partial hospitalization
services.
After consideration of the public comments received, we will ask
the APC Panel to provide advice at its next meeting regarding the
possible reconfiguration of APC 0323 to resolve a small 2 times
violation for CY 2009. For CY 2008, we are modifying our proposal for
two medication management services and will reassign CPT code 90862 and
HCPCS code M0064 from APC 0605 to APC 0606, with a median cost of
approximately $83.
IV. OPPS Payment 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 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
[[Page 66740]]
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 was 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 we 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.
For CY 2007, we based the device-dependent APC medians on CY 2005
claims, the most current data available at that time. In CY 2005 we
reinstated hospital reporting 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 procedure-
to-device edits to facilitate complete reporting of the charges for the
devices used in the procedures assigned to the device-dependent APCs.
For CY 2007 ratesetting, 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 token charge was
less than $1.01, and we removed those claims from the set used to
calculate the median costs of device-dependent APCs. In summary, for
the CY 2007 OPPS we set the median costs for device-dependent APCs
using only claims that passed the device edits and did not contain
token charges for the devices. Therefore, the median costs for these
APCs for CY 2007 were determined from claims data that generally
represented the full cost of the required device.
2. Payment Under the CY 2008 OPPS
For CY 2008, we proposed to calculate the median costs for device-
dependent APCs using three different sets of CY 2006 claims (72 FR
42719). We first calculated a median cost using all single procedure
claims that contained appropriate device codes (where there are edits)
for the procedure codes in those APCs. We then calculated a second
median cost using only claims that contain allowed device HCPCS codes
with charges for all device codes that were in excess of $1.00
(nontoken charge device claims). Third, we calculated the APC median
cost based only upon nontoken charge device claims with correct devices
that did not also contain the HCPCS modifier ``FB,'' reported in CY
2005 to identify that a procedure was performed using an item provided
without cost to the provider, supplier, or practitioner, or where a
credit was received for a replaced device (examples include, but are
not limited to, devices covered under warranty, devices replaced due to
defects, and free samples).
As expected, the median costs calculated based upon single
procedure bills that met all three criteria, that is, correct devices,
no token charges, and no ``FB'' modifier, were generally higher than
the median costs calculated using all single bills. We believed that
the claims that met these three criteria (appropriate device codes,
nontoken device charges, and no ``FB'' modifier) reflected the best
estimated costs for these device-dependent APCs when the hospital pays
the full cost of the device, and we proposed to base our CY 2008 median
costs on the medians calculated based upon these claims.
As a result of the effects of the proposed CY 2008 packaging
approach discussed in detail in section II.A.4. of the proposed rule on
median costs, we proposed to make some changes to CY 2007 device-
dependent APCs for CY 2008. Specifically, we proposed to delete APC
0081 (Noncoronary Angioplasty or Atherectomy); APC 0087 (Cardiac
Electrophysiologic Recording/Mapping); and APC 0670 (Level II
Intravascular and Intracardiac Ultrasound and Flow Reserve) due to the
migration of HCPCS codes to other APCs. Some of the HCPCS codes
assigned to these APCs in CY 2007 would be unconditionally packaged for
CY 2008. The median costs of the remaining HCPCS codes proposed for
separate payment in CY 2008 were significantly different than CY 2007
due to the proposed packaging of additional services. We believed that
reconfiguration of the APCs was necessary to ensure that the HCPCS
codes that would be separately paid in CY 2008 and that are assigned to
these APCs in CY 2007 would be assigned to APCs that are homogeneous
with regard to clinical characteristics and resource use in CY 2008.
The APCs we proposed for deletion ceased to be appropriate as a result
of the reassignment of the HCPCS codes that we proposed for continued
separate payment in CY 2008.
As proposed, the following seven APCs remained device-dependent
APCs for CY 2008, but we proposed to reassign certain HCPCS codes
mapped to these APCs for CY 2007 either to other APCs or among these
APCs for CY 2008 to ensure that, in view of the median costs that
resulted from the proposed CY 2008 packaging approach, the HCPCS codes
would be assigned to APCs that were homogeneous with regard to clinical
characteristics and
[[Page 66741]]
resource use for CY 2008: APC 0082 (Coronary Atherectomy); APC 0083
(Coronary Angioplasty and Percutaneous Valvuloplasty); APC 0085 (Level
II Electrophysiologic Evaluation); APC 0086 (Ablate Heart Dysrhythm
Focus); APC 0115 (Cannula/Access Device Procedures); APC 0427 (Level
III Tube Changes and Repositioning); and APC 0623 (Level III Vascular
Access Procedures). We also proposed to consider APC 0084 (Level I
Electrophysiologic Procedures) to be a device-dependent APC for CY 2008
because we proposed to reassign many of the HCPCS codes that were
previously in APCs 0086 and 0087 to APC 0084.
As a result of the proposed APC reconfigurations resulting from
HCPCS code migration, we noted that it was not appropriate to compare
the proposed CY 2008 OPPS median costs for these eight APCs to the CY
2007 OPPS final rule median costs that were the basis for the CY 2007
OPPS payment rates. When we compared the median costs for the other
device-dependent APCs with stable proposed CY 2008 configurations in
comparison with CY 2007, the median costs for 26 APCs increased, some
of them by significant amounts, and the median costs for 5 APCs
decreased. We believed that these median costs represented valid
estimates of the relative costs of the services in these APCs, both
with regard to the increases and the decreases that appeared when the
proposed CY 2008 median costs were compared to the CY 2007 median costs
on which the payment rates for these APCs were based.
Therefore, we proposed to base the payment rates for CY 2008 for
all device-dependent APCs on their median costs calculated using only
single bills that meet the three selection criteria discussed in detail
above. We did not believe that any special payment policies were
needed, as we believed that the claims data we proposed to use for
ratesetting would ensure that the costs of the implantable devices were
adequately and appropriately reflected in the median costs for these
device-dependent APCs.
We received a number of public comments on our CY 2008 proposed
payment methodology for device-dependent APCs. A summary of the public
comments and our responses follow.
Comment: Commenters supported the proposal to set the median costs
for device-dependent APCs using only claims that meet the three
selection criteria described in the proposed rule (that is, pass the
device edits, do not contain token charges, and do not have the without
cost/full credit modifier ``FB''), and urged CMS to continue to use
device edits to ensure that hospitals bill Level II HCPCS device codes
in addition to CPT codes for device-dependent procedures. Commenters
also suggested certain refinements to CMS' ratesetting methodology for
device-dependent APCs. One commenter asked for implementation of the
March 2007 APC Panel's recommendation to edit and return for correction
all claims that contain an HCPCS code for a separately payable device
but do not contain a CPT code assigned to a procedural APC. Another
commenter requested that at least 2 full years of data be used to set
rates for device-dependent APCs, as it may take hospitals several
months before they bill new Level II HCPCS device codes correctly, and
also asked that we implement a payment floor to prevent large decreases
in payment and promote stability in payment rates from year to year.
Another commenter asked CMS to redefine ``token charge'' for cochlear
implants to mean any amount lower than the amount the commenter
specified should be charged.
Response: We agree that it is appropriate to base the median costs
for device-dependent APCs on claims that contain the correct devices,
do not contain token charges, and do not contain the ``FB'' modifier.
However, we do not believe that it would be appropriate to define
``token charge'' at particular amounts for particular devices based on
external data or otherwise because hospitals are free to set their
charges for all items and services based on their own judgment. We
encourage hospitals to develop their charges, revenue centers, and
internal processes as they find appropriate. We have no reason to
believe, in any given case other than a token charge reported according
to CMS' instructions, that the charge on a claim is not an appropriate
charge by a hospital established for that specific service.
We agree that claims processing edits for services and items
integral to the performance of certain OPPS procedures paid under the
OPPS are an important element of our ratesetting methodology and,
therefore, we will continue to require that correct devices be billed
with certain HCPCS procedure codes for services that require devices.
Moreover, we have expanded their use within and beyond device-dependent
APCs (see sections II.A.2. and II.A.4.c.(5) of this final rule with
comment period for a discussion of the March 2007 APC Panel's
recommendation and measures we are taking to improve claims data for
diagnostic radiopharmaceuticals by using edits). In general, however,
we limit edits to the services, items, and procedures we believe
require extra vigilance to capture all associated charges in
recognition of the additional administrative burden these edits create
for hospitals, and the inherent complexity of ensuring that the edits
we do implement appropriately anticipate all clinical circumstances.
Particularly for packaged items and services including expensive
devices, we believe these edits ensure that high cost items are
reported on appropriate claims, so that the procedural payment rates
fully incorporate the costs of the items that are required for the
procedures. For other items, services, and procedures, we believe that
hospitals have strong incentives to report charges accurately to
Medicare and all other payers, and that these charges are sufficient to
provide accurate data. Another important component of ensuring we use
the most accurate data available for OPPS device-dependent APC
ratesetting is using the most current claims data and cost reports.
Therefore, we believe that it would be inconsistent to wait until we
have 2 full years of claims data before we update payment rates.
We also do not believe it is necessary to adjust our standard
device-dependent ratesetting methodology for CY 2008 by implementing a
payment floor to ensure beneficiary access. The only decline of more
than 10 percent between the CY 2008 final rule APC medians and the CY
2007 final rule medians is found in APC 0418 (Insertion of Left
Ventricular Pacing Electrode). As discussed in the proposed rule (72 FR
42720), we believe that this decline and variation in the median cost
for APC 0418 was the result of improvements in provider billing and a
relatively small number of single bills from a small number of
providers furnishing the service. We believe that the median cost we
calculated from the CY 2006 data is a reasonable estimate of the cost
of the insertion of the left ventricular lead. Furthermore, the
fluctuation of payment rates is to a certain degree inherent and
expected in a prospective payment system (see section II.A of this
final rule with comment period for a broader discussion of the
variation in APC payment rates from year to year). We note that we have
put into place reverse device edits for CY 2007 that will continue in
CY 2008, where we require hospitals reporting certain implantable
device HCPCS codes, such as ICDs, to report an appropriate procedure
for the device's use. We do not believe it is necessary to implement a
payment floor for this procedure, or any other device-
[[Page 66742]]
dependent procedure, to prevent large decreases in payment.
Comment: One commenter suggested that CMS should consider creation
of composite APCs for device-dependent procedures, such as ICD
implantation, where the device costs can vary significantly based on
the type of device used. The commenter suggested that payment for these
composite APCs would be based on the combination of the device
implantation CPT code and the existing Level II HCPCS code for the
particular device. According to the commenter, this would minimize
administrative burden for providers, allow coding to remain consistent
across payers, and enable more appropriate payment for procedures with
varying device costs.
Response: Composite APCs provide a single payment for two or more
major procedures that are commonly performed together, in order to
promote efficiency by increasing the size of the payment bundle. We do
not agree that the payment methodology outlined by this commenter, to
base payment on the combination of the device implantation CPT code and
the existing device code, is consistent with the concept of composite
APCs as described in the proposed rule and as finalized in section
II.A.4.d. of this final rule with comment period. The scenario
described by the commenter largely describes the current packaging of
device payment into the payment for the procedure, except that we
generally base payment on all of the devices associated with a
procedure as a mechanism to promote the efficient utilization of
resources. The recommended approach could actually reduce packaging
under the OPPS by creating small and more specific payment bundles,
rather than increasing the size of the payment bundles to provide
hospitals with the flexibility to manage their resources as they
control costs. To establish a separate APC for each combination of a
procedure and a particular device used, as described by the commenter,
would create incentives for the use of the most expensive device rather
than creating incentives for efficiency and therefore is contrary to
the principles of a prospective payment system.
Comment: Several commenters requested that CMS use external data
for ratesetting. While some commenters called for the broad-scale use
of external data to identify and adjust payment for technologies they
perceived to be underpaid both in the past and under the current
proposal, other commenters focused on the use of external data in
ratesetting for particular APCs (for example, several commenters asked
that CMS redefine the token charge criteria and adjust payment for
cochlear implants to reflect the device's estimated hospital invoice
price). According to commenters, external data could be used to rectify
the effects of charge compression, without committing CMS to reliance
on any particular data source. In addition, commenters requested that
CMS protect the confidentiality of any external data used in
ratesetting, because manufacturers and hospitals may be unwilling to
release proprietary information without assurances that CMS would not
release that information to the public.
Response: We review all information that is brought to our
attention by stakeholders as part of the public comment process, and we
have a general policy that all data we consider in ratesetting, whether
internal or external, will be made available to the public, including
any personally identifiable or confidential business information (for
example, see the discussion of Inspection of Public Comments in the CY
2008 OPPS/ASC proposed rule (72 FR 42628)). We have not systematically
used external data to validate the median costs derived from claims
data, because external data typically are furnished by parties with
special interest in a particular item or service. The foundation of a
system of relative weights is the relativity of the costs of all
services to one another, as derived from a standardized system that
uses standardized inputs and a consistent methodology. One of the
principles behind the use of median costs for weight setting in a
budget neutral payment system like the OPPS is to allow fair and
equitable distribution of payment among hospitals, based on their mix
of services provided to Medicare beneficiaries, by determining the
appropriate relativity in resource use among services. The median costs
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 prospective payment system that is
not intended to pay reasonable costs. For these reasons, 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 fundamental to the integrity of the OPPS. Similarly, we do not
believe that it is reasonable or appropriate to exclude specific claims
from ratesetting if the hospital charge for a particular item does not
exceed an established threshold such as the manufacturer's estimated
cost of the item.
After considering the public comments received on this proposal, we
are finalizing our proposed payment policies for device-dependent APCs,
without modification, for CY 2008. The CY 2008 payment rates for
device-dependent APCs are based on their median costs calculated from
CY 2006 claims and the most recent cost report data, using only claims
that pass the device edits, do not contain token charges for devices,
and do not have a modifier signifying that the device was furnished
without cost or with full credit. We do not think it is necessary or
appropriate to apply a maximum payment reduction floor. Consistent with
data from the proposed rule, payment rates based on final rule data
show increases for the majority of APCs for which comparison to CY 2007
payment rates is appropriate. As discussed in the proposed rule (72 FR
42720 through 42721), we found these differences in payment rates from
CY 2007 to CY 2008 to be attributable to a variety of factors,
including the availability of more complete claims data for CY 2008 and
the packaging approach that is new for CY 2008. Furthermore, as we have
stated in the past, some variation in relative costs from year to year
is be expected in a prospective payment system, particularly for low
volume device dependent APCs such as APC O681 (Knee Arthroplasty),
which increases 37 percent from CY 2007 to CY 2008. However, even in
the case of these low volume device dependent APCs, we continue to
believe that the median costs calculated from the single bills that
meet the three criteria represent the most valid estimated relative
costs of these services to hospitals when they incur the full cost of
the devices required to perform the procedures. In addition, we note
that we will maintain established device edits for procedures
previously assigned to device-dependent APCs that were packaged or
moved to APCs that are not device-dependent for CY 2008, in order to
ensure that the full costs associated with these services continue to
be represented adequately in claims data.
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. As discussed in detail
in section III.D.6.b. of this final rue with comment period, we are
adding APC 0293 (Level V Anterior Segment Eye Procedures) to the
[[Page 66743]]
list of device-dependent APCs for CY 2008, as reflected in Table 24
below.
Table 24.--CY 2008 Median Costs for Device-Dependent APCs
[Note that N/A indicates APCs for which the CY 2007 OPPS medians are not comparable to the CY 2008 medians, due
to HCPCS code migration for CY 2008.]
----------------------------------------------------------------------------------------------------------------
Count of
CY 2007 CY 2008 CY 2008 providers
final rule final rule final rule billing in
APC SI APC title pass edit, pass edit, pass edit, the final
nontoken nontoken nontoken CY 2008
median cost median cost frequency data
----------------------------------------------------------------------------------------------------------------
0039............. S................ Level I Implantation $11,451 $11,732 2,950 653
of Neurostimulator.
0040............. S................ Percutaneous $3,457 $4,013 5,177 1,040
Implantation of
Neurostimulator
Electrodes, Excluding
Cranial Nerve.
0061............. S................ Laminectomy or $5,145 $5,213 1,413 462
Incision for
Implantation of
Neurostimulator
Electrodes, Excluding
Cranial Nerve.
0082............. T................ Coronary or Non N/A $5,506 4,758 962
Coronary Atherectomy.
0083............. T................ Coronary or Non N/A $2,855 41,944 1,728
Coronary Angioplasty
and Percutaneous
Valvuloplasty.
0084............. S................ Level I N/A $603 7,381 616
Electrophysiologic
Procedures.
0085............. T................ Level II N/A $2,976 4,291 719
Electrophysiologic
Evaluation.
0086............. T................ Level III N/A $5,842 420 164
Electrophysiologic
Procedures.
0089............. T................ Insertion/Replacement $7,557 $7,654 668 370
of Permanent
Pacemaker and
Electrodes.
0090............. T................ Insertion/Replacement $6,007 $6,344 584 334
of Pacemaker Pulse
Generator.
0104............. T................ Transcatheter $5,360 $5,600 674 233
Placement of
Intracoronary Stents.
0106............. T................ Insertion/Replacement $3,138 $4,374 406 281
of Pacemaker Leads
and/or Electrodes.
0107............. T................ Insertion of $18,607 $21,001 501 228
Cardioverter-
Defibrillator.
0108............. T................ Insertion/Replacement/ $23,205 $25,471 3,719 616
Repair of
Cardioverter-
Defibrillator Leads.
0115............. T................ Cannula/Access Device N/A $1,868 1,398 705
Procedures.
0202............. T................ Level VII Female $2,627 $2,687 10,851 1,895
Reproductive Proc.
0222............. S................ Implantation of $11,099 $15,150 1,465 612
Neurological Device.
0225............. S................ Implantation of $13,514 $13,889 254 168
Neurostimulator
Electrodes, Cranial
Nerve.
0227............. T................ Implantation of Drug $10,658 $11,569 1,117 477
Infusion Device.
0229............. T................ Transcatheter $4,184 $5,570 8,004 1,256
Placement of
Intravascular Shunts.
0259............. T................ Level VI ENT $25,351 $24,739 868 174
Procedures.
0293............. T................ Level V Anterior N/A $5,335* N/A N/A
Segment Eye
Procedures.
0315............. S................ Level II Implantation $14,846 $16,988 691 203
of Neurostimulator.
0384............. T................ GI Procedures with $1,402 $1,572 7,484 1,464
Stents.
0385............. S................ Level I Prosthetic $4,840 $5,262 648 340
Urological Procedures.
0386............. S................ Level II Prosthetic $8,396 $9,067 3,683 887
Urological Procedures.
0418............. T................ Insertion of Left $18,778 $16,342 219 152
Ventricular Pacing
Elect.
0425............. T................ Level II Arthroplasty $6,551 $7,688 441 278
with Prosthesis.
0427............. T................ Level III Tube Changes N/A $966 13,556 1,293
and Repositioning.
0622............. T................ Level II Vascular $1,385 $1,517 36,920 2,408
Access Procedures.
0623............. T................ Level III Vascular N/A $1,817 54,632 2,746
Access Procedures.
0625............. T................ Level IV Vascular $5,100 $5,143 8 7
Access Procedures.
0648............. T................ Level IV Breast $3,130 $3,560 503 321
Surgery.
0652............. T................ Insertion of $1,805 $1,932 3,801 1,099
Intraperitoneal and
Pleural Catheters.
0653............. T................ Vascular $1,979 $2,546 1,700 713
Reconstruction/
Fistula Repair with
Device.
0654............. T................ Insertion/Replacement $6,891 $6,876 1,896 634
of a permanent dual
chamber pacemaker.
0655............. T................ Insertion/Replacement/ $9,328 $8,810 2,169 554
Conversion of a
permanent dual
chamber pacemaker.
0656............. T................ Transcatheter $6,618 $7,451 3,486 399
Placement of
Intracoronary Drug-
Eluting Stents.
0674............. T................ Prostate Cryoablation. $6,646 $7,720 2,222 383
0680............. S................ Insertion of Patient $4,437 $4,442 1,577 718
Activated Event
Recorders.
0681............. T................ Knee Arthroplasty..... $12,569 $17,281 317 59
----------------------------------------------------------------------------------------------------------------
\*\ In CY 2006, there were not HCPCS codes to describe all devices that could be used in this procedure.
3. Payment When Devices Are Replaced With Partial Credit to the
Hospital
In recent years there have been several field actions and recalls
as a result of implantable device failures. 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 order to ensure that the payment
we proposed for CY 2008 pays hospitals appropriately when they incur
the full cost of the device, we calculated the CY 2008 median costs for
device dependent APCs using only claims that contain the correct device
code for the procedure. We also did not use claims that contain token
charges for these expensive devices or that contain the ``FB''
modifier, which would signify that the device was replaced without cost
or with a full credit for the cost of the device being replaced.
Similarly, to ensure equitable payment when the hospital receives a
device without cost or receives a full credit for the cost of the
device being replaced, for CY 2007 we implemented a payment policy that
reduces the payment for selected device-dependent APCs when the
hospital receives certain replacement
[[Page 66744]]
devices without cost or receives a full credit for the device being
replaced (71 FR 68077).
The CY 2007 final payment policy when devices are replaced without
cost or when a full credit for a replaced device is furnished to the
hospital applies to those APCs that meet three criteria as described in
the CY 2007 OPPS/ASC final rule with comment period (71 FR 68072
through 68077). Specifically, all procedures assigned to the selected
APCs must require implantable devices that would be reported if device
replacement procedures were performed, 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), and
the device offset amount must be significant, which for purposes of
this policy is defined as exceeding 40 percent of the APC cost. We also
restricted the devices to which the APC payment adjustment would apply
to a specific set of costly devices 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.
As discussed in the CY 2008 proposed rule (72 FR 42726), we
examined the offset amounts calculated from the CY 2008 proposed rule
data and the clinical characteristics of APCs to determine whether the
APCs to which the no cost or full credit replacement policy applies in
CY 2007 continue to meet the criteria for CY 2008 and to determine
whether other APCs to which the policy does not apply in CY 2007 would
meet the criteria for CY 2008. Based on data available for the proposed
rule, we concluded that one additional APC met the criteria for
inclusion under this policy and that one APC currently on the list
ceases to meet the criteria. Specifically, we proposed to add APC 0625
(Level IV Vascular Access Procedures) to the list of APCs to be
adjusted in cases of full or partial credit for replaced devices (as
discussed below) and to add the device described by device code C1881
(Dialysis access system (implantable)) that is implanted in a procedure
assigned to APC 0625 to the list of devices to which this policy
applies. We proposed to add APC 0625 and device code C1881 for CY 2008
because they met the criteria for inclusion in this policy. In
particular, the single surgical procedure (CPT code 36566 (Insertion of
tunneled centrally inserted central venous access device, requiring two
catheters via two separate venous access sites; with subcutaneous
port(s)) assigned to APC 0625 always requires an implantable device
that is reported, the proposed CY 2008 APC device offset percent was
greater than 40 percent, and the device is of a type that is surgically
implanted in the patient, where it remains at least temporarily.
Furthermore, costly devices described by device code C1881 are
implanted in the procedure assigned to APC 0625. We also found that APC
0229 (Transcatheter Placement of Intravascular Shunts) ceased to meet
the criteria because the device offset percent for this APC, when
calculated from proposed rule data, was less than 40 percent. Moreover,
we believed that the devices that would be implanted in the procedures
assigned to this APC are not of a type that would be amenable to
removal and replacement in a device recall or warranty situation.
Therefore, we proposed to remove APC 0229 from the list of APCs to
which the no cost or full credit and proposed partial credit reduction
policies would be applicable for CY 2008. Table 38 of the proposed rule
(42 CFR 42727) contained the device offset amounts that we proposed to
apply to the specified APCs in cases of no cost or full or partial
credit for replaced devices for the CY 2008 OPPS.
As discussed in the proposed rule (72 FR 42724), subsequent to the
issuance of the CY 2007 OPPS/ASC final rule with comment period, we had
many inquiries from hospitals that asked whether the reduction would
also apply in cases in which there was a partial credit for the cost of
a device that failed or was otherwise covered under a manufacturer
warranty. Those inquiring explained that cases of partial credit are
the vast majority of cases involving devices that have failed or
otherwise must be replaced under warranty. They indicated that in some
cases the devices failed, and in other situations the patient's energy
needs exceeded the capacity of the device and thus the device ceased to
be useful before the end of the warranty period. They told us that a
typical industry practice for some types of devices was to provide a 50
percent credit in cases of device failure (including battery depletion)
under warranty if a device failed at 3 years of use (failure during the
first 3 years would result in a full device credit). The credit would
be prorated further over time between 3 and 5 years after the initial
device implantation, as the useful life of the device declined. As
promulgated in the CY 2007 OPPS/ASC final rule with comment period and
codified at Sec. 419.45, the CY 2007 reduction policy does not apply
to cases in which there is a partial credit toward the replacement of
the device.
In addition to our concern over the replacement of implantable
devices at no cost to hospitals due to device recalls, device failure,
or other clinical situations, we believed that it is equally as
important that timely information be reported and analyzed regarding
the performance and longevity of devices replaced in partial credit
situations. This issue is particularly timely due to the recent recall
of 73,000 ICDs and cardiac resynchronization therapy defibrillators
(CRT-Ds) because of a faulty capacitor that can cause the batteries to
deplete sooner than expected. In some cases, patients will require more
frequent monitoring of their device function and early device
replacement. (We refer readers to the Web site: http://www.fda.gov/cdrh/news for Questions and Answers posted April 20, 2007 on this
recall.) Therefore, we believed that hospitals should report
occurrences of devices being replaced under warranty or otherwise with
a partial credit granted to the hospital so that we could identify
systematic failures of devices or device problems through claims
analysis and so that we could make appropriate payment adjustments in
these cases. Collecting data on a wider set of device replacements
under full and partial credit situations would assist in developing
comprehensive summary data, not just a subset of data related to
devices replaced without cost or with a full credit to the hospital. In
the proposed rule, we explained that we are mindful of the need to use
our claims history, where possible, to promote early awareness of
problems with implantable medical devices and to promote high quality
medical care with regard to the devices and the services in which they
are used.
We also are concerned with the issue of the increased Medicare and
beneficiary liability for the monitoring costs that are required as a
result of the worldwide recall of these 73,000 devices. Specifically,
the manufacturer of the devices that have been most recently recalled
recommends that patients with the recalled device consult with their
physician in each case and, in some cases, begin a routine of monthly
evaluations. We would expect that not only could extra visits to
physicians' offices or HOPDs be necessary, but additional diagnostic
tests may also be needed to care for the beneficiaries who have the
recalled devices. Thus, even when the device does not immediately
require replacement, we are concerned that the potential greater costs
to Medicare and to the beneficiary or his or her
[[Page 66745]]
secondary payor for these unforeseen extra services may be substantial
and burdensome. We will be actively assessing how we can identify
additional health care costs and Medicare expenditures associated with
device recall actions and exploring what actions could be appropriate
in the case of these additional monitoring and related expenses. In the
proposed rule, we specifically invited public comment on this issue to
inform our future review and analyses (72 FR 42724).
Moreover, the payment rates for the APCs into which the costs of
the most expensive devices are packaged are set based on the assumption
that the hospital incurs the full cost of the device. To continue to
pay the full APC rate when the hospital receives a partial credit
toward the cost of a very expensive device would result in excessive
and inappropriate payment for the procedure and its packaged costs.
Some hospitals have told us that they do not reduce their charges for
the device being implanted or used in the procedure in cases in which
they receive a partial credit for the device, even in cases in which
the credit is for as much as 50 percent of the cost of an expensive
device.
For CY 2008, we proposed to create an HCPCS modifier that would be
reported in all cases in which the hospital receives a partial credit
toward the replacement of a medical device listed in Table 39 of the
proposed rule (72 FR 42727). These devices are the same devices to
which our policy governing payment when the device is furnished to the
provider without cost or with full credit would apply for CY 2008. As
we discussed in the CY 2007 OPPS/ASC final rule with comment period (71
FR 68071), we selected these devices because they have substantial
device costs and because the device is implanted in the beneficiary at
least temporarily and, therefore, can be associated with an individual
beneficiary. This proposed partial credit policy would enhance our
ability to track the replacement of these implantable medical devices
and may permit us to identify trends in device failure or limited
longevity. Moreover, it would enable us to reduce the APC payment in
cases in which the hospital receives a partial credit towards the cost
of the replacement device being implanted. We believed that this
proposal was a logical extension of our policy regarding reduction of
the APC payment in cases in which the provider furnishes the device
without cost or with a full credit to the hospital.
Specifically, as discussed in more detail below, we proposed to
reduce the payment for the APC into which the device cost is packaged
by one half of the amount of the offset amount that would apply if the
device were being replaced without cost or with full credit, but only
where the amount of the device credit is greater than or equal to 20
percent of the cost of the new replacement device being implanted. We
also proposed to base the beneficiary's copayment on the reduced APC
payment rate so that the beneficiary shares in the hospital's reduced
costs. We believed that it would be inequitable to set the payment
rates for the procedures into which payment for these devices is
packaged on the assumption that the hospital always incurs the full
cost for these expensive devices but to not adjust the payment when the
hospital receives a partial credit for a failed or otherwise replaced
device. Accordingly, we believed that it would be appropriate to make
an equitable adjustment to the APC payment to ensure that the Medicare
program payment made for the service and the beneficiary's liability
are appropriate in these cases in which the hospital's device costs are
significantly reduced. We proposed changes to Sec. 419.45(a) and (b)
to reflect our proposed policy of reducing the OPPS payment when
partial credit for the device cost is received by the hospital for a
failed or otherwise replaced device.
Due to the absence of current reporting of the cases in which
hospitals receive a partial credit for replaced devices and to our
belief, based on conversations with hospital staff, that hospitals do
not reduce their device charges to reflect the credits, we had no data
to determine empirically by how much we should reduce the payment for
the procedural APC into which the costs of these devices are packaged.
However, device manufacturers and hospitals have told us that a common
scenario is that, if a device fails 3 years after implantation, the
hospital would receive a 50 percent credit towards a replacement
device. Therefore, we proposed to reduce the payment for these device-
dependent APCs by half of the reduction that would apply when the
hospital receives a device without cost or receives a full credit for a
device being replaced. That is, we proposed to reduce the payment for
the APC by half of the offset amount that represents the cost of the
device packaged into the APC payment. In the absence of claims data on
which to base a reduction factor, but taking into consideration what we
have been told is common industry practice, we believed that reducing
the amount of payment for the device dependent APC by half of the
estimated cost of the device packaging represents a reasonable and
equitable reduction in these cases.
In the proposed rule (72 FR 42725), we also considered whether to
propose to require hospitals to reduce their charges in proportion to
the partial credit they receive for the device so that, in future
years, we would have cost data reported consistently on which we could
consider basing the amount of reduction to the payment for the
procedure in cases of a partial device credit. However, we were
concerned that such a requirement could impose an administrative burden
on hospitals that would outweigh the potential benefit of a more
accurate reduction to payment in these cases. Therefore, we
specifically requested comments on the extent to which any
administrative burden would be balanced or compensated for by the
potential payment accuracy benefit of an empirically based reduction to
payment in these cases (72 FR 42725).
In addition, we proposed to take this reduction only when the
credit is for 20 percent or more of the cost of the new replacement
device, so that the reduction would not be taken in cases in which more
than 80 percent of the cost of the replacement device has been incurred
by the hospital. We were concerned that the burden to hospitals of
requiring that they report cases in which the partial credit for the
device being replaced is less than 20 percent of the cost of the new
replacement device would be greater than the benefit to the Medicare
program and the beneficiary. In addition, if the partial credit is less
than 20 percent of the cost of the new replacement device, then
reducing the APC payment for the device implantation procedure by 50
percent of the packaged device cost would provide too low a payment to
hospitals providing the necessary device replacement procedures.
Therefore, we proposed that the new HCPCS partial credit modifier would
be reported and the partial credit reduction would be taken only in
cases in which the credit is equal to or greater than 20 percent of the
cost of the new replacement device.
As discussed in the proposed rule (72 FR 42725), even in the
absence of specific instructions to reduce the device charges in
partial credit cases, we could monitor the charges that are submitted
for devices reported with the proposed partial credit modifier to see
if hospitals appear to be reflecting partial device credits in their
charges for these implantable devices. We believed that we could use
pattern analysis to
[[Page 66746]]
determine if a hospital that is reporting the device with the partial
credit modifier is charging at a lower rate for the same device when
the modifier appears with the procedure in which the device is used
than in cases without reporting of the modifier. As proposed, if we
found that hospitals were adjusting their charges to reflect the
reduced costs of these devices, we would explore whether revising the
amount of the reduction could be appropriate.
In summary, we proposed the following: (1) To create a HCPCS
modifier to be reported on a procedure code listed in Table 38 of the
proposed rule if a device listed in Table 39 of that rule is replaced
with partial credit from the manufacturer that is greater than or equal
to 20 percent of the cost of the replacement device; and (2) to reduce
the payment for the procedure by 50 percent of the amount of the
estimated packaged cost of the device being replaced when the modifier
is reported with a procedure code that is assigned to an APC in Table
38. We believed that this policy is necessary to pay equitably for
these services when the hospital receives a partial credit for the cost
of the device being implanted.
At the September 2007 meeting of the APC Panel, the Panel
recommended that CMS explore whether hospitals could report a modifier
to reflect the amount of a partial credit for a device as a percentage
of the cost of the replacement device. According to the Panel, this
approach could signify that there was a partial credit and provide data
for use in determining the amount of reduction that could be taken in
future years.
We received many public comments on our proposal to reduce the APC
payment for certain implantation procedures when specific devices are
replaced with a partial credit to the hospital. A summary of the public
comments and our responses follow.
Comment: The majority of commenters agreed that neither Medicare
nor beneficiaries should have to pay based on a device's full cost when
the hospital receives a substantial credit from the manufacturer for
that device, and supported the premise underpinning the proposed policy
that hospitals'' charges and OPPS payment rates based on those charges
currently do not reflect partial credits for replaced devices. Some
commenters argued, however, that all manufacturer rebates, from volume
discounts to partial credits for replaced devices, are applied to
hospitals' cost reports, and as such are reflected in hospitals' CCRs.
Others said that hospitals often do adjust their charges to reflect
partial credits for replaced devices and that a payment adjustment in
such cases was not necessary, because payment rates calculated
according to the standard OPPS ratesetting methodology for device-
dependent APCs already reflect such occurrences. Those opposed to the
proposed policy in its entirety also noted that it would be
operationally and administratively difficult to implement and that it
would result in insufficient payment to hospitals.
Most commenters that agreed with the premise behind the proposed
policy to reduce Medicare payment for devices replaced with partial
credit supported implementation of the proposed policy, but requested
modifications or a delay in implementation of the policy. The majority
of these commenters argued that CMS should raise the partial credit
threshold to which this policy would apply to 50 percent of the cost of
the replacement device, consistent with the policy CMS recently
implemented for devices replaced with partial credit for services paid
under the FY 2008 IPPS. Commenters stated that consistency in policies
across hospital inpatient and outpatient payment systems would reduce
confusion, promote compliance, and decrease the administrative burden
for hospitals. The commenters also argued that a threshold as low as a
20 percent credit toward the cost of the replacement device would not
justify the operational and administrative burdens of returning the
replaced devices to manufacturers for evaluation and applying manual
billing adjustments. They were concerned that because of these
administrative burdens, hospitals may not return the failed devices to
manufacturers at all, thereby interfering with manufacturers' quality
surveillance programs and preventing the type of data collection the
proposed policy is meant to promote. According to commenters, a
threshold of 50 percent would ensure that hospitals do not have to deal
with these administrative burdens when the credit is nominal or
relatively inconsequential relative to the overall procedure payment
and unlikely to result in significant savings to the Medicare program.
Some commenters noted that a partial credit threshold of 20 percent,
with a payment reduction of 50 percent, would result in inadequate
payment to hospitals when the credit received was anywhere between 20
percent and 50 percent of the cost of the device.
Response: We agree with the commenters' concerns regarding the
threshold percentage to which a partial credit adjustment would be
applied. We are increasing the threshold to which the partial credit
reduction policy will apply to cases involving a credit of 50 percent
or more toward the total cost of the replacement device. Commenters
expressed significant concerns about potential administrative and
operational burdens associated with partial credits for small
percentages of device costs, and we agree that the partial credit
adjustment policy should not apply if only a nominal portion of the
cost of the device is at issue. We also agree that consistency in
payment policies across hospital inpatient and outpatient payment
systems is important and should be maintained whenever appropriate, as
is true in this case. Raising the partial credit threshold to which
this policy will apply also addresses concerns that the 50 percent
reduction to Medicare payment for the replaced device would be more
than the partial credit received in some cases.
We disagree with assertions that OPPS payment for device-dependent
APCs already reflects partial credits to hospitals for replaced
devices. We go to great lengths to ensure that payment rates for
device-dependent APCs reflect the full costs of devices by excluding
claims that contain token charges and/or the ``FB'' modifier. We
continue to believe that in most cases, hospitals charge the full
amount for the replaced device, although they may have incurred much
less than the full cost of the device. While it may be true that some
hospitals adjust their charges to reflect the partial credits they
receive for replaced devices, we believe this is a small minority.
Therefore, we believe our ratesetting methodology generally results in
median costs that reflect the full costs of these devices. We also
continue to believe that it is likely the reduced hospital costs
associated with steady, low volume warranty replacements of implantable
devices may never be reflected in the CCRs used to adjust charges to
costs for devices, because those CCRs are overwhelmed by the volume of
other items attributed to the cost centers. Therefore, our median costs
for device-dependent APCs would not reflect the reduced hospital costs
associated with partial credit device replacement procedures.
As discussed in the proposed rule (72 FR 42725 through 42726), we
also do not agree that hospitals would refrain from returning a device
removed from a patient to a manufacturer in order to justify not
reporting the partial credit modifier to Medicare. We continue to
believe that hospitals have a strong interest in ensuring that
manufacturers know as soon as possible when there are problems with the
devices provided to their patients, whether the result would
[[Page 66747]]
be a full or partial credit for the failed device. In addition, we
believe that hospitals, key participants in the broader healthcare
system, are concerned with device performance, patient health, and
health care quality from the broader public health perspective and are
committed to appropriate reporting to improve the quality of future
health care that leads to better health outcomes for patients.
Moreover, we do not believe that hospitals would intentionally fail to
report to Medicare the service furnished correctly and completely with
the partial credit modifier when the modifier applies, because the
hospital would then knowingly submit incorrect information on the
claim.
Comment: Many commenters urged OPPS adoption of the same billing
options for hospitals as are available under the IPPS for billing
devices replaced with partial credit. Specifically, they requested
hospitals be allowed to: (1) Submit the claims for replacement devices
immediately without the HCPCS modifier signifying partial credit for a
replacement device and later, if a credit is ultimately issued, submit
a claim adjustment with the appropriate coding; or (2) hold the claim
until a credit determination is made. According to the commenters,
credits are determined after a case-by-case review by the manufacturer
following explant and replacement of the device, which can take 8 weeks
or longer. During this time, hospitals often do not know whether or how
much credit the manufacturer will provide and cannot submit a bill for
the replacement device implantation procedure, creating substantial
payment delays. In addition, commenters were concerned about the
administrative burden of providing paper invoices or other information
to their fiscal intermediary or MAC indicating the hospital's normal
cost of the device or the amount of the credit received.
Several commenters referenced the September 2007 meeting of the APC
Panel, where the Panel recommended that CMS explore whether hospitals
could report a modifier to reflect the amount of a partial credit for a
device as a percentage of the amount of the replacement device. While
one commenter supported this approach, other commenters expressed
concerns about the administrative burden associated with this
alternative. They stated that constructing a modifier in this way may
be too easily confused with existing numeric modifiers used in
conjunction with CPT coding. Commenters also shared CMS' concerns about
hospitals reducing their charges in proportion to the partial credit
they receive for a replaced device. They encouraged CMS to work with
providers to develop the least burdensome approach to incorporate
payment reductions for devices replaced with partial credit based on
empirical data.
Response: In order to report that they received a partial credit of
50 percent or more of the cost of a replacement device, hospitals will
have the option of either: (1) Submitting the claims immediately
without the HCPCS modifier signifying partial credit for a replacement
device and submitting a claim adjustment with the HCPCS modifier at a
later date once the credit determination is made; or (2) holding the
claim until a determination is made on the level of credit. We
understand commenters' concerns about potential delays that could occur
while a returned device is being evaluated to determine whether and by
how much a credit will be applied. We agree that hospitals should have
the same billing options, when appropriate, under the OPPS as are
available under the IPPS. As described in the FY 2008 IPPS final rule
(72 FR 47250), we believe that these billing options will facilitate
more efficient administration of the policy by allowing the hospital to
gather and report all of the information it needs to be paid correctly
by Medicare, without the need to suspend claims or delay payment.
We share commenters' concerns about the administrative and coding
burdens that could be associated with the September 2007 APC Panel's
recommendation to report a modifier to reflect the amount of a partial
credit for a device as a percentage of the cost of the replacement
device so we are not adopting that recommendation for CY 2008. We also
note that the claims processing system for Part B hospital outpatient
bills does not have the capacity to accommodate non-uniform HCPCS
modifiers. Instead, CMS will recognize a new ``FC'' modifier, effective
January 1, 2008, that reads: ``Partial credit received for replaced
device.'' 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 with partial credit under warranty,
recall, or field action is one of the devices in Table 26 below
(hospitals should not append the modifier to the HCPCS procedure code
if the device is not listed in Table 26). Claims containing the ``FC''
modifier will not be accepted unless the modifier is on a procedure
code with status indicator ``S,'' ``T,'' ``V,'' or ``X.'' If the APC to
which the procedure code is assigned is one of the APCs listed in Table
25 below, the fiscal intermediary or MAC will reduce the unadjusted
payment rate for the procedure by an amount equal to the percent in
Table 26 for partial credit device replacement multiplied by the
unadjusted payment rate (if the ``FC'' modifier is assigned to a
procedure code that is not in Table 26, then no adjustment will be
taken). The adjustment amounts for no cost, full credit, and partial
credit cases are included in Table 25 below.
We believe that it is appropriate to treat the services subject to
the APC payment reduction in cases of devices replaced with partial
credit like any other service, and to apply the standard reduction
policies. Therefore, the partial credit adjustment will occur before
wage adjustment and before the assessment to determine if the
reductions for multiple procedures (signified by the presence of more
than one procedure on the claim with status indicator ``T''),
discontinued services (signified by modifier 73) or reduced services
(signified by modifier 52) apply, similar to what occurs when a device
is replaced at full credit or with no cost to the hospital (see 71 FR
68076 for more discussion).
Comment: Some commenters requested that we provide clarification of
key elements of the proposal, stating that it was unclear what ``cost''
should be considered when determining the situations to which the
partial credit policy should apply, and what constitutes a
``replacement'' device. For example, some commenters pointed out that
volume discounts can result in reduced costs for hospitals, and that at
times devices are replaced at full cost when a new, improved technology
becomes available. Some commenters also expressed interest in any OPPS
data we may have about the number of cases to which this policy would
apply.
Response: The partial credit policy only applies when hospitals
receive partial credit for the cost of a device that is replaced due to
failure or other problems while the device is still under warranty, or
when there is a recall or field action. The policy does not apply when
hospitals receive routine rebates such as volume discounts. Hospitals
should continue to incorporate these other types of rebates into their
cost reports so that these savings will be reflected in the hospitals'
CCRs. Neither the partial credit payment reduction for replaced
devices, nor the payment reduction for devices replaced with full
credit or at no cost, apply if the hospital pays the full price for the
device.
We acknowledge the interest providers have in the data resulting
[[Page 66748]]
from our reporting requirements for devices replaced at no cost or with
full or partial credit. We will consider what types of information
could be of value to hospitals as we continue to analyze claims-based
reporting of full and partial device credit cases, particularly when CY
2007 claims data become available.
Comment: One commenter objected to the application of a different
offset percentage to APC 0385 (Level I Prosthetic Urological
Procedures) than to APC 0386 (Level II Prosthetic Urological
Procedures) for purposes of the adjustment when a device is replaced in
cases of no cost or full or partial credit. The commenter stated that
the ratio of device costs to overall procedure costs is identical in
APCs 0385 and 0386, and that the device offset percentage should be at
least 80 percent for both APCs.
Response: Our hospital claims data and cost reports indicate the
device offset percentage for APC 0385 is 52 percent, and the device
offset percentage for APC 0386 is 64 percent, calculated according to
our standard methodology for establishing the device offset percentage
(71 FR 68073). Because the surgical procedures assigned to these two
APCs are different from one another from clinical and resource
perspectives as evidenced by the CY 2008 median costs of approximately
$5,262 and $9,067 for APCs 0385 and 0386, respectively, and because the
distinct HCPCS device codes allowed in the procedure-to-device-edits
for the various services assigned to the two APCs are different, we
would expect that their device offset percentages also would differ.
Therefore, we conclude that the device cost in APC 0386 is higher than
the device cost in APC 0385, and that neither device offset percentage
should be equal to 80 percent.
After consideration of the public comments received, we are
finalizing a modified policy for certain procedures involving partial
credit for a replacement device. Specifically, we will reduce the
payment for an implantation procedure assigned to APCs listed in Table
25, below, by one half of the device offset that would be applied if a
replacement device were provided at no cost or with full credit, if the
credit is 50 percent or more of the replacement device cost. We will
recognize the new modifier ``FC'' for reporting these cases, and we are
not adopting the recommendation of the APC Panel to utilize a modifier
that specifically reflects the amount of a partial credit for a device
as a percentage of the cost of the replacement device. Accordingly, we
are implementing the proposed changes to Sec. Sec. 419.45(a) and (b)
with modification to reflect the 50 percent partial device credit
threshold to which the policy will apply. Beneficiary copayment will be
based on the reduced payment amount. We will continue to evaluate how
we might refine our methodology for reducing the payment for the
procedural APCs into which the costs of the devices in 25 below are
packaged based on the claims data we receive as this policy is
implemented. We also will continue to monitor charges that are
submitted for devices reported with the partial credit modifier ``FC''
to see if hospitals appear to be reflecting partial device credits in
their charges for these implantable devices.
We also are implementing our proposals to add APC 0625 to the list
of APCs to be adjusted in cases of no cost or full or partial credit
for replaced devices, to remove APC 0229 from that list, and to add the
device described by device code C1881 that is implanted in a procedure
assigned to APC 0625 to the list of devices to which this policy
applies.
Table 25.--Adjustments to APCs in Cases of No Cost or Full or Partial Credit for Replaced Devices
--------------------------------------------------------------------------------------------------------------------------------------------------------
CY 2007 CY 2008 CY 2008 CY 2008 CY 2008
reduction reduction reduction CY 2008 adjusted adjusted
APC SI APC title for full for full for partial payment payment for payment for
credit case credit case credit case rate full credit partial
(percent) (percent) (percent) case credit case
--------------------------------------------------------------------------------------------------------------------------------------------------------
0039.................. S..................... Level I Implantation of 78.85 82.73 41.37 $11,877 $2,051 $6,964
Neurostimulator.
0040.................. S..................... Percutaneous Implantation 54.06 56.27 28.14 4,063 1,777 2,920
of Neurostimulator
Electrodes, Excluding
Cranial Nerve.
0061.................. S..................... Laminectomy or Incision 60.06 60.60 30.30 5,278 2,079 3,679
for Implantation of
Neurostimulator
Electrodes, Excluding
Cranial Nerve.
0089.................. T..................... Insertion/Replacement of 77.11 72.99 36.50 7,748 2,093 4,921
Permanent Pacemaker and
Electrodes.
0090.................. T..................... Insertion/Replacement of 74.74 76.01 38.01 6,423 1,541 3,982
Pacemaker Pulse Generator.
0106.................. T..................... Insertion/Replacement/ 41.88 56.25 28.13 4,428 1,937 3,183
Repair of Pacemaker and/
or Electrodes.
0107.................. T..................... Insertion of Cardioverter- 90.44 89.11 44.56 21,262 2,315 11,789
Defibrillator.
0108.................. T..................... Insertion/Replacement/ 89.40 89.24 44.62 25,787 2,775 14,281
Repair of Cardioverter-
Defibrillator Leads.
0222.................. S..................... Implantation of 77.65 84.86 42.43 15,337 2,322 8,830
Neurological Device.
0225.................. S..................... Implantation of 79.04 80.57 40.29 14,061 2,732 8,397
Neurostimulator
Electrodes, Cranial Nerve.
0227.................. T..................... Implantation of Drug 80.27 80.73 40.37 11,713 2,257 6,985
Infusion Device.
0259.................. T..................... Level VI ENT Procedures... 84.61 82.94 41.47 25,046 4,273 14,659
0315.................. S..................... Level II Implantation of 76.03 86.15 43.08 17,199 2,382 9,790
Neurostimulator.
0385.................. S..................... Level I Prosthetic 83.19 51.56 25.78 5,327 2,580 3,954
Urological Procedures.
[[Page 66749]]
0386.................. S..................... Level II Prosthetic 61.16 63.53 31.77 9,180 3,348 6,264
Urological Procedures.
0418.................. T..................... Insertion of Left 87.32 82.52 41.26 16,544 2,892 9,718
Ventricular Pacing Elect.
0625.................. T..................... Level IV Vascular Access N/A 58.88 29.44 5,207 2,141 3,674
Procedures.
0654.................. T..................... Insertion/Replacement of a 77.35 77.13 38.57 6,961 1,592 4,276
permanent dual chamber
pacemaker.
0655.................. T..................... Insertion/Replacement/ 76.59 74.62 37.31 8,919 2,264 5,591
Conversion of a permanent
dual chamber pacemaker.
0680.................. S..................... Insertion of Patient 76.40 73.15 36.58 4,497 1,208 2,852
Activated Event Recorders.
0681.................. T..................... Knee Arthroplasty......... 73.37 82.86 41.43 17,495 2,993 10,244
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 26.--Devices for Which the ``FB'' or ``FC'' Modifier Must Be
Reported with the Procedure Code When Furnished Without Cost/Full Credit
or Partial Credit for a Replaced Device
------------------------------------------------------------------------
Device HCPCS code Short descriptor
------------------------------------------------------------------------
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.
C1881............................. Dialysis access system.
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. The three
categories listed in Table 40 of the CY 2008 OPPS/ASC proposed rule,
along with their expected expiration dates, were established for pass-
through payment in CY 2006 or CY 2007, as noted. Under our 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.
Of these 3 device categories, there is 1 that would be eligible for
pass-through payment for at least 2 years as of December 31, 2007; that
is, device category code C1820 (Generator, neurostimulator
(implantable), with rechargeable battery and charging system). In the
CY 2007 OPPS/ASC final rule with comment period (71 FR 68078), we
finalized our proposal to expire device category C1820 from pass-
through device payment after December 31, 2007.
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 2007, 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 reported 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. Final Policy
In the CY 2008 OPPS/ASC proposed rule, we stated that we were
implementing in CY 2008 the final decision that we discussed in the CY
2007 OPPS/ASC final rule with comment period that finalized the
expiration date of pass-through status for device category C1820 (71 FR
68078). Therefore, as of January 1, 2008, we will discontinue pass-
through payment for device category code C1820. In accordance with our
established policy, we will package the costs of the device assigned to
this device category into the costs of the procedures with which the
device was billed in CY 2006, the year of hospital claims data used for
this OPPS update. See section III.D.8. of this final rule with comment
period for a discussion of our
[[Page 66750]]
final CY 2008 payment for the implantation of neurostimulators.
The 2 device categories that were established for pass-through
payment as of January 1, 2007, HCPCS code C1821 (Interspinous process
distraction device (implantable)) and HCPCS code L8690 (Auditory
osseointegrated device, includes all internal and external components),
will be active categories for pass-through payment for 2 years as of
December 31, 2008. Therefore, we proposed that these categories expire
from pass through device payment as of December 31, 2008.
We received a number of public comments concerning this proposal. A
summary of the public comments and our responses follow.
Comment: A number of commenters objected to our proposal to expire
device category L8690 from pass-through payment after December 31, 2008
and recommended that we maintain category code L8690 on pass-through
status until the end of CY 2009, allowing a third year of pass-through
payment. These commenters claimed that one year of claims data, that
is, CY 2007 (which would be used to develop the CY 2009 payment rates
for the associated implantation procedures) would be insufficient to
establish an accurate procedure payment rate that reflected the costs
of implanting the device. They based this recommendation on several
reasons. They claimed that there were low volumes of charges by
hospitals to Medicare for HCPCS code L8690. One of the commenters, the
applicant to establish the pass-through category, projected utilization
of 525 devices in the first year of device pass-through payment at the
time of the application, but stated that CMS CY 2006 claims data for
the proposed rule included only 230 total claims for procedures to
implant the device. The commenter indicated that it did not expect the
number of implantation procedures to increase substantially in CYs 2007
and 2008. Commenters also claimed that given the history of hospital
billing problems for implantable devices, the new code L8690 was
generally unknown in CY 2006 and some data might not have been
accurately reported. Several commenters explained that the four
different procedure codes associated with implantation of
osseointegrated devices, CPT codes 69714 (Implantation, osseointegrated
implant, temporal bone, with percutaneous attachment to external speech
processor/cochlear stimulator; without mastoidectomy) through 69718
(Replacement (including removal of existing device), osseointegrated
implant, temporal bone, with percutaneous attachment to external speech
processor/cochlear stimulator; with mastoidectomy) demonstrated wide
variation in hospital costs, from $5,200 through $9,200, and this cost
variation also pointed to current insufficient data for the procedures
to implant osseointegrated devices. One commenter recommended that we
extend pass-through status for L8690 through CY 2010.
Response: Several commenters reported that the procedures in which
L8690 was implanted were low volume OPPS procedures. We agree that
these procedures were low volume in CY 2006, with only 255 total claims
under the OPPS. However, we would not expect that these procedures
would ever be commonly performed in the Medicare population because the
specific clinical indications for implantation of osseointegrated
implants are most frequently found in younger populations. Therefore,
the osseointegrated implant procedures would likely continue to exhibit
low claim volumes relative to many other procedures paid under the
OPPS. In fact, the projected utilization of 525 devices by one
commenter for CY 2006 would also be considered low volume for the OPPS,
but we regularly pay prospectively for many services where there are
fewer than several hundred OPPS services performed each year. We
believe that several hundred implantation procedure claims from CY 2007
should be sufficient for CY 2009 ratesetting, when we would first
package payment for the device cost of osseointegrated devices that no
longer had pass-through status. During CYs 2007 and 2008, hospitals
have a strong financial incentive to report appropriate charges for the
device's use, because they are paid separately for the device, based on
charges adjusted to cost during the device's pass-through payment
period. We note that while there are four CPT codes for the
osseointegrated device implantation procedures, the vast majority of CY
2006 claims were for CPT code 69714, for which we had 240 total claims.
The majority of these claims were single claims that would be available
for use in establishing the procedure's median cost. While the other
three procedures had only a few CY 2006 claims each and displayed the
variable costs that commonly result from a small number of claims, we
believe that they are similar to CPT code 69714 from both clinical and
resource perspectives and note that all four procedures require the
implantable device for their performance. Therefore, we believe that
our CY 2007 data for implantation of osseointegrated device procedures
should be sufficient to allow accurate ratesetting for CY 2009 when the
device cost would be packaged, so there would be no reason to continue
the pass-through status of L8690 beyond the 2 year period that ends as
of December 31, 2008. Moreover, as to the commenter who requested pass-
through status for L8690 through CY 2010, we note that the statute at
section 1833(t)(6)(C) precludes pass-through payments for a category of
devices for more than 3 years.
Comment: A commenter stated that we should extend pass-through
payment for HCPCS code C1821 (Interspinous process distraction device
(implantable)), presumably for the additional year allowed under the
statute.
Response: The commenter stated that we should continue pass-through
payment for the spinous process distraction device reported with C1821
but provided no explicit rationale for this recommendation or for how
much longer than the 2 years we proposed for the pass-through payment
for C1821. We expect that there would be sufficient CY 2007 claims data
that reflected the cost of the interspinous distraction device for the
CY 2009 OPPS update, so that the device cost could be appropriately
packaged into the APC payment for the associated implantation
procedures with which the device was reported. During CYs 2007 and
2008, hospitals have a strong financial incentive to report appropriate
charges for the device's use, because they are paid separately for the
device, based on charges adjusted to cost during the device's pass-
through payment period. The associated procedure codes, specifically
CPT codes 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)) were new for CY 2006, where they were assigned to
APC 0050 (Level II Musculoskeletal Procedures Except Hand and Foot) on
an interim final basis. See section III.D.8. of this final rule with
comment period for a discussion of the final CY 2008 APC assignments of
these procedures to APC 0050. After CY 2008, HCPCS code C1821 would
have had 2 full years of pass-through payment, and we believe that it
would be appropriate
[[Page 66751]]
to package the costs of C1821 into payment for the implantation
procedures with which the device was billed, according to our standard
methodology, for CY 2009. We see no reason to extend the period of pass
through payment for C1821 beyond December 31, 2008.
After consideration of the public comments received, we are
finalizing our proposal, without modification, to expire device
categories L8690 and C1821 from transitional pass-through payment after
December 31, 2008.
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 device 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 that was 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 was applied only when a new device category was billed with a
HCPCS procedure code that was 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 hospital claims data may
either have overestimated or underestimated the 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 percent 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, 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 (Implantation of Neurological Device) 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 a CY 2006
offset amount for that category in Program Transmittal No. 804, dated
January 3, 2006. (We subsequently were informed that some rechargeable
neurostimulators described by device category C1820 may also be used
and billed with a CPT code that
[[Page 66752]]
maps to APC 0039 (Level I Implantation of Neurostimulator). We
announced an offset amount for device category C1820 when billed with a
procedure code that maps to APC 0039 in Program Transmittal No. 1209,
dated March 21, 2007.)
For CY 2006, we used 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 category codes. In addition, during CY 2005 we
implemented device edits for many services that require devices and for
which appropriate device category 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.
For CY 2007, we reviewed the two new device categories, C1821 and
L8690, to determine whether device costs associated with the new
categories were packaged into the existing APC structure based on CY
2005 claims data. As indicated earlier, under our established policy,
if we determine that the device costs associated with a 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 related services indicated that the median costs
for the applicable APC 0256 (Level V ENT Procedures (for L8690)) and
APC 0050 (Level II Musculoskeletal Procedures Except Hand and Foot (for
C1821)) did not contain costs for devices that were similar to those
described by the new device categories. Therefore, we set the
respective offsets to $0.
We believed that use of the most current claims data to establish
offset amounts when they are needed to ensure appropriate payment was
consistent with our stated policy; therefore, we proposed to continue
to do so for the CY 2008 OPPS. Specifically, if we created a new device
category for payment in CY 2008, 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 were already packaged into the existing APC structure, as
indicated earlier. If we concluded that some related device costs were
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 percent for those APCs with which the new
category would be reported.
b. Final Policy
For CY 2008, we proposed to continue to review each new device
category on a case-by-case basis as we have done since CY 2004, to
determine whether device costs associated with the new category were
packaged into the existing APC structure. If we determined that, for
any new device category, no device costs associated with the new
category were packaged into existing APCs, we proposed to continue our
current policy of setting the offset amount for the new category to $0
for CY 2008. There are currently two new device categories that will
continue for pass through payment in CY 2008. These categories,
described by HCPCS codes L8690 and C1821, currently have an offset
amount equal to $0 because we could not identify device related costs
in the procedural APCs we expect would be billed with either of the two
categories L8690 or C1821, that is, in APC 0256 or APC 0050,
respectively. We proposed that the offsets for CY 2008 for L8690 and
C1821 remain set to $0, because we could not identify device costs
packaged in the related procedural APCs that were closely identifiable
with these device categories, based on the claims data for CY 2006, the
claims data year for our CY 2008 OPPS update.
We proposed to continue our existing policy of establishing new
categories in any quarter when we determined that the criteria for
granting pass through status for a device category were met. If we
created a new device category and determined that our CY 2006 claims
data contained a sufficient number of claims with identifiable costs
associated with the new category of devices in any APC with which it is
billed, we proposed to establish an offset amount greater than $0 and
to reduce the transitional pass through payment for the device by the
related procedural APC offset amount. If we determined that a device
offset amount greater than $0 was appropriate for any new category that
we created, we proposed to announce the offset amount in the program
transmittal that announced the new category.
In summary, for CY 2008, we proposed to use CY 2006 hospital claims
data to calculate device percentages and potential offsets for new
device categories established in CY 2008. We also proposed to publish
through program transmittals any new or updated offsets that we
calculated for CY 2008, corresponding to newly created categories or
existing categories eligible for pass-through payment, respectively.
We received no public comments on our proposed continuation of our
current policy to establish offset amounts for new device categories
eligible for pass-through payments, and, therefore, we are adopting our
proposed policy stated above as final for CY 2008.
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, 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 provided for certain
``new'' drugs and biological agents that were not being paid for as an
HOPD 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. For pass-through
payment purposes, radiopharmaceuticals are included as ``drugs.'' Under
the statute, transitional pass-through payments can be made for at
least 2 years but not more than 3 years. CY 2008 pass-through drugs and
biologicals are assigned status indicator ``G'' as indicated in Addenda
A and B to the CY 2008 OPPS/ASC proposed rule and this final rule with
comment period.
Section 1833(t)(6)(D)(i) of the Act specifies that the pass-through
payment amount, in the case of a drug or biological, is the amount by
which the amount determined under section 1842(o) of the Act (or, if
the drug or
[[Page 66753]]
biological is covered under a competitive acquisition contract under
section 1847B of the Act, an amount determined by the Secretary equal
to the average price for the drug or biological for all competitive
acquisition areas and year established under such section as calculated
and adjusted by the Secretary) for the drug or biological exceeds the
portion of the otherwise applicable Medicare OPD fee schedule that the
Secretary determines is associated with the drug or biological. This
methodology for determining the pass-through payment amount is set
forth in Sec. 419.64 of the regulations, which specifies that the
pass-through payment equals the amount determined under section 1842(o)
of the Act minus the portion of the APC payment that CMS determines is
associated with the drug or biological. 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 term ``ASP methodology'' and
``ASP-based'' are inclusive of all data sources and methodologies
described therein. Additional information on the ASP methodology can be
found on the CMS Web site at: http://www.cms.hhs.gov/
McrPartBDrugAvgSalesPrice/01--overview.asp#TopOfPage.
As noted above, 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's 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 on the CMS Web site at:
http://www.cms.hhs.gov/CompetitiveAcquisforBios.
For CYs 2005, 2006, and 2007, we estimated the OPPS pass-through
payment amount for drugs and biologicals to be zero based on our
interpretation that the ``otherwise applicable Medicare OPD fee
schedule'' amount was equivalent to 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). We concluded for those years that
the resulting difference between these two rates would be zero. OPPS
pass-through payment estimates for drugs and biologicals in CY 2008 can
be found in section VI. of this final rule with comment period.
The pass through application and review process is explained on the
CMS Web site at: http://www.cms.hhs.gov /HospitalOutpatientPPS/04--
passthrough--payment.asp.
2. Drugs and Biologicals With Expiring Pass-Through Status in CY 2007
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. In Table 41 of the CY
2008 OPPS/ASC proposed rule (72 FR 42730), we proposed to allow the
expiration of the pass-through status for seven drugs and biologicals
on December 31, 2007. While it is standard OPPS practice to delete
temporary C-codes if an alternate permanent HCPCS code becomes
available for purposes of OPPS billing and payment, there were no
temporary C-codes used to identify the seven pass-through drugs that
were proposed for expiring pass-through status on December 31, 2007.
Table 27 below includes the CY 2008 permanent HCPCS codes of drugs and
biologicals with expiring pass-through status as of December 31, 2007.
We received several public comments regarding a drug proposed to
expire from pass-through status at the end of CY 2007. A summary of the
comments and our responses follow.
Comment: A few commenters requested that CMS continue pass-through
status for HCPCS code Q4079 (Injection, Natalizumab, 1 mg) for an
additional year. The commenters stated that, while HCPCS code Q4079 was
granted pass-through status beginning April 2005, the manufacturer of
this drug voluntarily suspended sales of the drug prior to that date in
February 2005. Therefore, the commenters believed that the period of
pass-through under the OPPS did not begin until the drug resumed
marketing in June 2006 or until the manufacturer again began shipping
the drug to providers in July 2006. The commenters noted that, under
these circumstances, pass-through payment had not been made for the 2
year pass-through minimum. Therefore, they believed that pass-through
status should continue through CY 2008.
Response: According to our regulations at 42 CFR 419.64, pass-
through status begins on the date that CMS makes its first pass-through
payment for the drug or biological. As the commenters noted, HCPCS code
Q4079 was approved for OPPS pass-through status beginning in April
2005. However, the manufacturer of the product voluntary suspended
marketing of the product 2 months prior to April 2005. Therefore, in
order to determine when pass-through payments were first made for this
product, we examined OPPS claims data for HCPCS code Q4079 for the
second, third and fourth quarters of CY 2005. While we found a few
claims from this time period from several different hospitals, we
believe that these claims were incorrectly coded. The typical dose of
HCPCS code Q4079 is 300 mg infused every 4 weeks. The hospital claims
billed during these three quarters of 2005 reported a median of only
one unit per day, although the descriptor of HCPCS code Q4079 specifies
``per 1 mg.'' In comparison, hospital claims show a median of 300 units
per day billed after this product resumed marketing in July 2006. In
addition, while there were a few hospital claims for HCPCS code Q4079
submitted in CY 2005, we received no claims for HCPCS code Q4079 during
the first two quarters of CY 2006. Therefore, we believe that the CY
2005 claims were miscoded, so that the first pass-through payment for a
correctly coded use for HCPCS code Q4079 was actually not made until
July 2006. As a drug that began pass-through status in July 2006 would
continue with pass-through status in CY 2008, we are continuing pass-
through status in CY 2008 for HCPCS code Q4079.
In addition, in accordance with our standard practice to replace
temporary HCPCS codes with permanent ones when a permanent HCPCS code
becomes available, we are deleting HCPCS code Q4079 (Injection,
Natalizumab, per 1 mg), effective December 31, 2007, and replacing it
with HCPCS code J2323 (Injection, Natalizumab, 1 mg), effective January
1, 2008. We have identified this drug in Table 27 below and in Addendum
B of this final rule with comment period
[[Page 66754]]
using HCPCS code J2323 and assigned it status indicator ``G.''
After consideration of the public comments received, we are
finalizing our proposed listing of drugs and biologicals whose pass-
through status expires on December 31, 2007, with modification so that
pass-through status for HCPCS code Q4079 (HCPCS code J2323 beginning in
CY 2008) continues in CY 2008. In Table 27 below, we list the six drugs
and biologicals whose pass-through status will expire on December 31,
2007.
Table 27.--Drugs and Biologicals for Which Pass-Through Status Expires December 31, 2007
----------------------------------------------------------------------------------------------------------------
CY 2008 HCPCS CY 2007 HCPCS CY 2008 Descriptor CY 2008 SI CY 2008 APC
----------------------------------------------------------------------------------------------------------------
J2278.................. J2278.................. Ziconotide injection..... K..................... 1694
J2503.................. J2503*................. Pegaptanib sodium K..................... 1697
injection.
J7311.................. J7311.................. Fluocinolone acetonide K..................... 9225
implt.
J8501.................. J8501.................. Oral aprepitant.......... K..................... 0868
J9027.................. J9027.................. Clofarabine injection.... K..................... 1710
J9264.................. J9264*................. Paclitaxel protein bound. K..................... 1712
----------------------------------------------------------------------------------------------------------------
* 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 2008
In the CY 2008 OPPS/ASC proposed rule (72 FR 42731), we proposed to
continue pass through status in CY 2008 for 13 drugs and biologicals.
These items, which were approved for pass-through status between April
1, 2006 and July 1, 2007, were listed in Table 42 of the proposed rule.
The APCs and HCPCS codes for these drugs and biologicals listed in
Table 42 were assigned status indicator ``G'' in Addenda A and B to the
proposed rule.
Section 1833(t)(6)(D)(i) of the Act sets the amount of pass-through
payment for pass-through drugs and biologicals (the pass-through
payment amount) as the difference between the amount authorized under
section 1842(o) of the Act (or, if the drug or biological is covered
under a CAP under section 1847B of the Act, an amount determined by the
Secretary equal to the average price for the drug or biological for all
competitive acquisition areas and year established under such section
as calculated and adjusted by the Secretary) and the portion of the
otherwise applicable fee schedule amount that the Secretary determines
is associated with the drug or biological. Given our CY 2008 proposal
to provide payment for nonpass-through separately payable drugs and
biologicals at ASP+5 percent as described further in section V.B.3 of
this final rule with comment period, in the proposed rule we stated our
belief that it would be most consistent with the statute to provide
payment for drugs and biologicals with pass through status that are not
part of the Part B drug CAP at a rate of ASP+6 percent, compared to
ASP+5 percent as the otherwise applicable fee schedule portion
associated with the drug or biological. The difference between ASP+6
percent and ASP+5 percent, therefore, would be the CY 2008 pass-through
payment amount for these drugs and biologicals. Thus, for CY 2008, we
proposed to pay for pass-through drugs and biologicals that are not
part of the Part B drug CAP at ASP+6 percent, equivalent to the rate
these drugs and biologicals would receive in the physician's office
setting in CY 2008.
Section 1842(o) of the Act also states that if a drug or biological
is covered under a CAP 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 year established as calculated and
adjusted by the Secretary. For CY 2008, we proposed to provide payment
for drugs and biologicals with pass-through status that are offered
under the Part B drug CAP at a rate equal to the Part B drug CAP rate.
Therefore, considering ASP+5 percent to be the otherwise applicable fee
schedule portion associated with these drugs or biologicals, the
difference between the Part B drug CAP rate and ASP+5 percent would be
the pass-through payment amount for these drugs and biologicals. HCPCS
codes that are offered under the CAP program as of April 1, 2007, are
identified in Table 28 below with an asterisk.
In the CY 2008 OPPS/ASC proposed rule, we proposed to continue
pass-through status for 13 drugs and biologicals. As stated previously,
it is standard OPPS practice to delete temporary C-codes if an
alternate permanent HCPCS code becomes available for purposes of OPPS
billing and payment. For CY 2008, HCPCS code C9232 (Injection,
idursulfase, 1 mg) is deleted and replaced with HCPCS code J1743
(Injection, idursulfase, 1 mg); HCPCS code C9233 (Injection,
ranibizumab, 0.5 mg) is deleted and replaced with HCPCS code J2778
(Injection, ranibizumab, 0.1 mg); and HCPCS code C9235 (Injection,
panitumumab, 10 mg) is deleted and replaced with HCPCS code J9303
(Injection, panitumumab, 10 mg).
In addition, in order to be consistent with the naming conventions
of the CMS HCPCS Workgroup, we have deleted HCPCS code C9350
(Microporous collagen tube of non-human origin, per centimeter length),
and replaced this code with HCPCS codes C9352 (Microporous collagen
implantable tube (Neuragen Nerve Guide), per centimeter length) and
C9353 (Microporous collagen implantable slit tube (NeuraWrap Nerve
Protector), per centimeter length) in order to more accurately identify
the two products that were previously described by HCPCS code C9350.
Similarly, we have deleted HCPCS code C9351 (Acellular dermal tissue
matrix of nonhuman origin, per square centimeter (Do not report C9351
in conjunction with J7345)) for CY 2008 and replaced it with HCPCS
codes J7348 (Dermal (substitute) tissue of nonhuman origin, with or
without other bioengineered or processed elements, without
metabolically active elements (Tissuemend) per square centimeter) and
J7349 (Dermal (substitute) tissue of nonhuman origin, with or without
other bioengineered or processed elements, without metabolically active
elements (Primatrix) per square centimeter).
We received several public comments regarding our proposal to
continue the pass-through status of certain drugs and biologicals for
CY 2008. A summary of the comments and our responses follow.
Comment: Several commenters noted support for specific drugs and
biologicals proposed for pass-through status in CY 2008 and urged CMS
to finalize the proposal for these items. The commenters also commended
CMS for proposing to provide payment for pass-through drugs and
biologicals at a
[[Page 66755]]
rate equal to the rate these drugs and biologicals would receive under
the Part B drug CAP program or in the physician's office setting.
Response: We appreciate the commenters' support for our proposed
policy. We are finalizing our proposal to provide pass-through payments
in CY 2008 for the drugs listed in Table 28 below. This table includes
the continuation of pass-through status for HCPCS code Q4079, as
discussed previously, and accounts for the coding changes presented
above.
Comment: One commenter disagreed with the decision to grant pass-
through status to HCPCS code J3473 (Injection, hyaluronidase,
recombinant, 1 USP unit) beginning in January 2007 and to continue this
drug in pass-through status through CY 2008. The commenter believed
that the product described by HCPCS code J3473 fails to meet the pass-
through criteria of newness and ``not insignificant costs.'' The
commenter claimed that hyaluronidase was available prior to December
31, 1996, and was captured in the initial OPPS payment rates and,
therefore should not be considered new. In addition, the commenter
explained that the FDA approval of this product was made based on the
section 505(b)(2) criteria, meaning that the product claimed to be
identical to products already approved by the FDA. This commenter also
noted that the administration of HCPCS code J3473 is typically billed
with ophthalmic procedures, not drug administration procedures. The
commenter asserted that when the cost significance test is performed
with APCs more likely to reflect ophthalmic procedures, such as APC
0246 (Cataract Procedures with IOL Insert), the cost significance test
for drug and biological pass-through status is not met.
The commenter further noted that, as a result of this drug being
granted pass through status, CMS created a market bias towards the use
of this product, as all other hyaluronidase products are currently
packaged. The commenter argued that this apparent market bias would be
further exacerbated as a result of the revised ASC payment system
policy of providing separate payment for OPPS separately payable drugs
that are provided in the ASC setting beginning in CY 2008, because the
majority of procedures that would be likely to use HCPCS code J3473 are
frequently performed in ASCs.
Response: Our criteria for reviewing pass-through applications are
available on the CMS Web site at: http://www.cms.hhs.gov/
HospitalOutpatientPPS/04--passthrough--payment.asp. Based on these
criteria, we reviewed the application submitted to us for HCPCS code
J3473 and approved pass-through status beginning on January 1, 2007. We
do not agree with the commenter that our decision was in error. The
drug met all criteria established for pass through payment for drugs
and biologicals. Therefore, as this drug has not met the 2-year minimum
pass-through time requirement, we are adopting our proposal to continue
pass-through status for HCPCS code J3473 for CY 2008.
Comment: One commenter requested that CMS clarify how payment would
be made for radiopharmaceutical products that are granted pass-through
status during CY 2008.
Response: Currently, there are no radiopharmaceuticals that would
have pass-through status in CY 2008. Consistent with OPPS payment for
drugs, biologicals, and radiopharmaceuticals without HCPCS codes, in CY
2008, payment for radiopharmaceuticals that are granted pass-through
status would be based on the ASP methodology. As stated above, for
purposes of pass-through payment, we consider radiopharmaceuticals to
be drugs under the OPPS. Therefore, if a radiopharmaceutical receives
pass through status during CY 2008, we will follow the standard ASP
methodology to determine its pass-through payment rate under the OPPS.
Because ASP data are not available for radiopharmaceuticals, we will
base the pass-through payment on the product's WAC. If WAC data are
also not available, we will then provide payment for the pass-through
radiopharmaceutical at 95 percent of its most recent AWP.
In the OPPS/ASC CY 2008 proposed rule, we used payment rates for
drugs with pass-through status based on the ASP data from the fourth
quarter of CY 2006 for budget neutrality estimates, impact analyses,
and completion of Addenda A and B to the proposed rule because these
were the most recent data available to us at that time. These payment
rates were the basis for drug payments in the physician's office
setting, effective April 1, 2007. As proposed, we used updated data in
the development of this final rule with comment period. That is, we
used the ASP data from the second quarter of CY 2007 (which are the
basis for drug payments in the physician's office setting, effective
October 1, 2007) in budget neutrality estimates, impact analyses, and
completion of Addenda A and B to this final rule with comment period.
In addition, we are finalizing our proposal to update these pass-
through payment rates on a quarterly basis on our Web site during CY
2008 if later quarter ASP submissions (or more recent WAC or AWP data,
as applicable) indicate that adjustments to the payment rates for these
pass-through drugs and biologicals are necessary. Although there are no
pass-through radiopharmaceuticals at this time for CY 2008, the payment
rate for a radiopharmaceutical with pass-through status would also be
adjusted accordingly.
As proposed, if a drug that has been granted pass-through status
for CY 2008 becomes covered under the Part B drug CAP, we will make the
appropriate adjustments to the payment rates for these drugs and
biologicals on a quarterly basis. For drugs and biologicals that are
currently covered under the CAP, we proposed to use the payment rates
calculated under that program that are in effect as of April 1, 2007,
which is the most recent update of these payment rates. We proposed to
update these payment rates if the rates change in the future.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to make separate
payment in CY 2008 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's
office setting (or under section 1847B of the Act, if the drug or
biological is covered under a CAP) only if we receive a pass-through
application for the drug or biological and pass-through status is
subsequently granted. Otherwise, we will pay ASP+5 percent for these
products in CY 2008. New radiopharmaceuticals with pass-through status
will be paid based on WAC or, if WAC is not available, based on 95
percent of the product's most recent AWP. We will update the payment
rates for pass-through drugs and biologicals quarterly, as new data
become available.
The drugs and biologicals that are continuing pass-through status
or have been granted pass-through status as of January 2008 for CY 2008
are included in Table 28 below.
[[Page 66756]]
Table 28.--Drugs and Biologicals With Pass-Through Status in CY 2008
----------------------------------------------------------------------------------------------------------------
CY 2007 HCPCS CY 2008 HCPCS CY 2008 Descriptor CY 2008 SI CY 2008 APC
----------------------------------------------------------------------------------------------------------------
C9239.................. Inj, temsirolimus........ G..................... 1168
C9350.................. C9352.................. Neuragen nerve guide, per G..................... 9350
cm.
C9350.................. C9353.................. Neurawrap nerve G..................... 1169
protector, cm.
J0129.................. J0129.................. Abatacept injection...... G..................... 9230
J0348.................. J0348.................. Anadulafungin injection.. G..................... 0760
J0894*................. J0894*................. Decitabine injection..... G..................... 9231
C9236.................. J1300.................. Eculizumab injection..... G..................... 9236
J1740.................. J1740.................. Ibandronate sodium G..................... 9229
injection.
C9232.................. J1743.................. Idursulfase injection.... G..................... 9232
J2248.................. J2248.................. Micafungin sodium G..................... 9227
injection.
Q4079.................. J2323.................. Natalizumab injection.... G..................... 9126
C9233.................. J2778.................. Ranibizumab injection.... G..................... 9233
J3243.................. J3243.................. Tigecycline injection.... G..................... 9228
J3473.................. J3473.................. Hyaluronidase recombinant G..................... 0806
Q4095.................. J3488.................. Reclast injection........ G..................... 0951
C9351.................. J7348.................. Tissuemend tissue........ G..................... 9351
C9351.................. J7349.................. Primatrix tissue......... G..................... 1141
J9261.................. J9261.................. Nelarabine injection..... G..................... 0825
C9235.................. J9303.................. Panitumumab injection.... G..................... 9235
----------------------------------------------------------------------------------------------------------------
* 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.
B. Payment for Drugs, Biologicals, and Radiopharmaceuticals Without
Pass Through Status
1. Background
Under the CY 2007 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.
Section 1833(t)(16)(B) of the Act, as added by section 621(a)(2) of
Pub. L. 108-173, sets the threshold for establishing separate APCs for
drugs and biologicals at $50 per administration for CYs 2005 and 2006.
Therefore, for CYs 2005 and 2006, we paid separately for drugs,
biologicals, and radiopharmaceuticals whose per day cost exceeded $50
and packaged the costs of drugs, biologicals, and radiopharmaceuticals
whose per day cost was equal to or less than $50 into the procedures
with which they were billed. For CY 2007, the packaging threshold for
drugs, biologicals, and radiopharmaceuticals that are not new and do
not have pass-through status was established at $55. The methodology
used to establish the $55 threshold for CY 2007 and our proposed
approach for future years are discussed in more detail in section
V.B.2. of this final rule with comment period.
In addition, for CY 2005 to CY 2007, we have provided an exemption
to this packaging determination for oral and injectable 5HT3 forms of
anti-emetic products. We discuss in section V.B.2. of this final rule
with comment period our final CY 2008 payment policy for these anti-
emetic products.
2. Criteria for Packaging Payment for Drugs and Biologicals
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.
In CY 2007, we used the fourth quarter moving average Producer Price
Index (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 then rounded the resulting dollar amount to the nearest $5
increment in order to determine the CY 2007 threshold adjustment amount
of $55.
Following the CY 2007 methodology (which is discussed in more
detail in the CY 2007 OPPS/ASC final rule with comment period (71 FR
68085 through 68086)), as proposed, we used updated fourth quarter
moving average PPI levels to trend the $50 threshold forward from the
third quarter of CY 2005 to the third quarter of CY 2008 and again
rounded the resulting dollar amount ($57.78) to the nearest $5
increment, which yielded a figure of $60. In performing this
calculation, we used the most up-to-date forecasted, quarterly PPI
estimates from CMS' Office of the Actuary (OACT). As actual inflation
for past quarters replaced forecasted amounts, the PPI estimates for
prior quarters were revised (compared with those used in the CY 2007
OPPS/ASC final rule with comment period) and were incorporated into our
calculation. Based on the calculations described above, we proposed a
packaging threshold for CY 2008 of $60. As stated in the CY 2007 OPPS/
ASC final rule with comment period (71 FR 68086), we believe that
packaging certain items is a fundamental component of a prospective
payment system, that packaging these items does not lead to
[[Page 66757]]
beneficiary access issues and does not create a problematic site of
service differential, that the packaging threshold is reasonable based
on the initial establishment in law of a $50 threshold 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. As indicated in the proposed rule, we did
not propose for CY 2008 to change this established approach to
establishing the general packaging threshold for drugs, biologicals,
and radiopharmaceuticals, in view of our proposed packaging approach
for the CY 2008 OPPS as outlined in section II.A.4. of that proposed
rule and our desire to move the OPPS toward a more encounter-based and
episode-based payment in the future. However, as noted in the proposed
rule, we will consider expanded packaging of payment for drugs,
biologicals, and radiopharmaceuticals for a future OPPS update (72 FR
42732). We believe that consideration of expanded packaging for drugs
and biologicals is particularly important, given the substantial
increase that has occurred in recent years in the proportion of HCPCS
codes for drugs, biologicals, and radiopharmaceuticals that are paid
separately, from 30 percent in CY 2003 to 50 percent in CY 2007. We
proposed for CY 2008 to expand the packaging of certain drugs and
radiopharmaceuticals, specifically contrast agents and diagnostic
radiopharmaceuticals as discussed in detail in section II.A.4.c.(5) and
(6) of this final rule with comment period. However, we continue to
believe that increased packaging of payment for drugs, biologicals, and
radiopharmaceuticals more generally under the OPPS could provide
significant incentives for hospital efficiency in adopting the most
cost-effective approaches to patient care, while providing hospitals
with maximum flexibility in managing their resources. Therefore, in the
proposed rule, we specifically solicited public comment regarding
recommended approaches to increase packaging of these products under
the OPPS and issues we should consider as we evaluate alternative
methodologies for the future (72 FR 42732).
For the third year, we proposed to continue exempting the oral and
injectable forms of 5HT3 anti-emetics products from packaging, thereby
making separate payment for all of these products. As we stated in the
CY 2005 OPPS final rule with comment period (69 FR 65779 through
65780), it is our understanding that chemotherapy is very difficult for
many patients to tolerate, as the side effects are often debilitating.
In order for Medicare beneficiaries to achieve the maximum therapeutic
benefit from chemotherapy and other therapies with side effects of
nausea and vomiting, anti-emetic use is often an integral part of the
treatment regiment. In the proposed rule, we stated our belief that we
should continue to ensure that Medicare payment rules do not impede a
beneficiary's access to the particular anti-emetic that is most
effective for him or her, as determined by the beneficiary and the
treating physician.
Comment: A few commenters disagreed with the proposed increase of
the packaging threshold to $60 and asked CMS to retain the $55
threshold for CY 2008. The commenters noted that the threshold has
experienced a 20 percent increase over 2 years, and that an increased
threshold threatens hospitals' ability to provide quality care without
compromising the range of services they offer. One commenter suggested
that CMS implement a contingency that would limit increases to the drug
packaging amount to the rate of increase in the ASP amount. Other
commenters suggested increasing the OPPS drug packaging threshold
either for a subset of items, or for all drugs, biologicals, and
radiopharmaceuticals. Another commenter recommended that CMS consider a
drug packaging methodology based on the relative cost of a drug in
comparison with the associated procedure, instead of continuing the
absolute cost methodology, proposed for CY 2008 at $60.
Response: We continue to believe that our approach of applying an
annual inflation adjustment factor to update the packaging threshold is
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 continue to be concerned that, absent a mechanism to update
the threshold, current relatively inexpensive drugs would begin to
receive separate payment over time. While we understand the commenters'
concerns that substantial increases in the threshold over a short
period of time may be undesirable, we do not believe that the changes
we have implemented over the past 2 years have jeopardized hospitals'
ability to provide quality patient care. In addition, we again note
that the updates to the OPPS drug packaging threshold have been
predicated on relevant inflation rates for prescription drugs.
Therefore, we continue to believe that our update methodology is
aligned closely with national industry figures and standards.
We agree with some commenters that an increased packaging threshold
would be supportive of our overall increased packaging efforts to
increase the size of the OPPS payment bundles. As stated above, we
believe that there are many benefits of increasing the drug packaging
threshold beyond the current level, one benefit being that items within
a group of drugs would potentially be paid according to a similar
methodology. During the September 2007 APC Panel meeting, the Panel
engaged in a discussion regarding a higher drug packaging threshold for
the OPPS, and while this discussion did not yield a recommendation, the
Panel expressed interest in the idea of an increased drug packaging
threshold. While we understand that there may be benefits to hospitals
when the drug packaging threshold is relatively low because they would
be paid separately for many drugs, we believe that a higher packaging
threshold could encourage efficiencies and provide hospitals more
flexibility in managing their resources associated with drug
administration services.
In addition, while we are unsure how a drug packaging threshold
based on relative drug costs in comparison to the associated procedure
costs would operate in a hospital outpatient setting, we believe that
further investigation of such a methodology could be warranted.
Therefore, in an effort to gain more information that may help us
determine the potential effects of an increased drug packaging
threshold based on either an absolute dollar amount or on a relative
dollar amount, we are again specifically requesting comments from
hospital stakeholders and interested individuals on the impact that
such a change would have on hospitals, and how such a methodology could
be developed, implemented, and updated.
Comment: Several commenters requested that CMS eliminate the drug
packaging threshold and provide separate payment for all Part B drugs.
The commenters noted that this would eliminate payment disparities
between the OPPS and the physician's office setting, so there would be
no site-of-service differential in providing drug therapies.
Response: We continue to believe that unpackaging payment for all
drugs, biologicals, and radiopharmaceuticals is inconsistent with the
concept of a prospective payment system and that such a change could
create an additional reporting burden for
[[Page 66758]]
hospitals. The OPPS and the MPFS that apply to physician's office
services 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 under 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 component of a service. Consistent with the MPFS
approach, separate payment is made for each drug provided in the
physician's office, but the OPPS packages payment for certain drugs
into the associated procedure payments for the APC group. Because of
the different payment policies, 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 results in limited beneficiary access to drug
administration services.
We note that, in CYs 2005 and 2006, the statutorily mandated drug
packaging threshold was set at $50, and we believe it is currently
appropriate to continue a modest drug packaging threshold for the CY
2008 OPPS. 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
recommendation to pay separately for all drugs, biologicals, and
radiopharmaceuticals for CY 2008.
Comment: Several commenters supported the proposal to continue to
exempt the oral and injectable forms of 5HT3 anti-emetic products (that
were listed in Table 43 of the proposed rule that is reprinted as Table
29 below) from packaging, thereby making separate payment for all of
the 5HT3 anti-emetic products. In addition, a few commenters requested
that CMS apply the same principle to other groups of drugs in order to
equalize payment methodologies across drugs in the same clinical group.
One commenter recommended that payment for all hyaluronidase products
be packaged.
Response: We appreciate the support of our proposal to continue
exempting the 5HT3 anti-emetic products from our packaging
determination. However, as discussed in the CY 2008 OPPS/ASC proposed
rule, as we consider moving to additional encounter based and episode-
based payment in future years, we may consider additional options for
packaging in the future. If we were to increase the OPPS drug packaging
threshold, we might no longer require a special exemption for these
products because all these products might be packaged under such an
approach. Similarly, a higher drug packaging threshold could eliminate
existing disparities in payment methodologies for other drug groups and
provide similar methods of payment across items in a group.
Nevertheless, while we may be interested in alternative threshold
methodologies for future ratesetting purposes, we realize that there
are existing situations where drugs in a particular category vary in
their payment treatment under the OPPS, with some drugs packaged and
other separately paid. We believe the challenges associated with
categorizing drugs to assess them for disparities are significant, and
we are not convinced that ensuring the same payment treatment for other
drug categories is essential at this time, beyond the proposal we made
for 5HT3 anti-emetics. Therefore, we do not believe that it would be
appropriate for CY 2008 to take any additional steps to ensure that all
drugs in a specific category are either separately paid or packaged, as
requested by some commenters.
After considering the public comments received, we are finalizing
our CY 2008 proposal, without modification, to again exempt the oral
and injectable forms of 5HT3 anti-emetic products listed in Table 29
below from our packaging methodology for CY 2008.
Table 29.--Anti-Emetics Exempted From CY 2008 $60 Packaging Threshold
------------------------------------------------------------------------
HCPCS code Short descriptor
------------------------------------------------------------------------
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
------------------------------------------------------------------------
For CY 2008, we proposed to calculate the per day cost of all
drugs, biologicals, and radiopharmaceuticals that had a HCPCS code in
CY 2006 and were paid (via packaged or separate payment) under the OPPS
using claims data from January 1, 2006, to December 31, 2006, to
determine their CY 2008 packaging status. In order to calculate the per
day costs for drugs, biologicals, and radiopharmaceuticals to determine
their packaging status in CY 2008, 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 70 FR 68638). To calculate the
proposed CY 2008 per day costs, we used an estimated payment rate for
each drug and biological of ASP+5 percent (which is the payment rate we
proposed for separately payable drugs and biologicals in CY 2008, as
discussed in more detail subsequently). As noted in the CY 2008 OPPS/
ASC proposed rule (72 FR 42733), we used the manufacturer submitted ASP
data from the fourth quarter of CY 2006 (rates that were used for
payment purposes in the physician's office setting, effective April 1,
2007) to determine the proposed per day cost. For items that did not
have an ASP based payment rate, we used their mean unit cost derived
from the CY 2006 hospital claims data to determine their per day cost.
As described in the proposed rule, we packaged items with a per day
cost less than or equal to $60 and identified items with a per day cost
greater than $60 as separately payable. Consistent with our past
practice, we crosswalked historical OPPS claims data from the CY 2006
HCPCS codes that were reported to the CY 2007 HCPCS codes that we
displayed in Addendum B to the proposed rule for payment in CY 2008.
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 that it is
also our policy to make an annual packaging determination only when we
develop the OPPS/ASC final rule for the update year. As indicated in
the proposed rule (72 FR 42733), only items that are identified as
separately payable in this final rule with comment period will be
subject to quarterly updates. As proposed, for our calculation of per
day costs of drugs, biologicals, and radiopharmaceuticals in this final
rule with comment period, we used ASP data from the first quarter of CY
2007, which is the basis for calculating payment rates for drugs and
biologicals in the physician's office setting using the ASP
methodology, effective July 1, 2007, along with updated hospital claims
data from CY 2006.
Consequently, the packaging status for drugs, biologicals, and
radiopharmaceuticals in this final rule with comment period using the
updated data may be different from their packaged status determined
based on the data used for the proposed rule. Under such circumstances,
we have
[[Page 66759]]
applied the following policies to these drugs, biologicals, and
radiopharmaceuticals whose relationship to the $60 threshold changes
based on the final updated data:
Drugs, biologicals, and radiopharmaceuticals that were
paid separately in CY 2007 and that were proposed for separate payment
in CY 2008, and then have per day costs equal to or less than $60,
based on the updated ASPs and hospital claims data used for the CY 2008
final rule with comment period, would continue to receive separate
payment in CY 2008.
Drugs, biologicals, and radiopharmaceuticals that were
packaged in CY 2007 and that were proposed for separate payment in CY
2008, and then have per day costs equal to or less than $60, based on
the updated ASPs and hospital claims data used for the CY 2008 final
rule with comment period, would remain packaged in CY 2008.
Drugs, biologicals, and radiopharmaceuticals for which we
proposed packaged payment in CY 2008 but then have per day costs
greater than $60, based on the updated ASPs and hospital claims data
used for the CY 2008 final rule with comment period, would receive
separate payment in CY 2008.
We note that HCPCS code J0594 (Injection, busulfan, 1 mg) was paid
separately in CY 2007 and was proposed for separate payment in CY 2008,
but had a final per day cost of approximately $37, which is less than
the $60 threshold, based on the updated ASPs and hospital claims data
used for this CY 2008 final rule with comment period. HCPCS code J0594
will continue to receive separate payment in CY 2008 according to the
established methodology set forth above.
In addition, there were several drugs and biologicals that we
proposed to package in the proposed rule and that now have per day
costs greater than $60 using updated ASPs and all of the hospital
claims data from CY 2006 used for this final rule with comment period.
In accordance with our established policy for such cases, for CY 2008
we will pay for these drugs and biologicals separately. Table 30 lists
the drugs and biologicals that were proposed as packaged, but that will
be paid separately in CY 2008.
Table 30.--Drugs and Biologicals Proposed as Packaged but With Final Per
Day Costs Above $60, for Which Separate Payment Will Be Made in CY 2008
------------------------------------------------------------------------
HCPCS Description
------------------------------------------------------------------------
J0190............................. Inj biperiden lactate/5 mg
J0600............................. Edetate calcium disodium inj
J1595............................. Injection glatiramer acetate
J2730............................. Pralidoxime chloride inj
J9270............................. Plicamycin (mithramycin) inj
------------------------------------------------------------------------
Also, according to our packaging policy described above, two drugs,
specifically HCPCS codes J0520 (injection, bethanechol chloride,
myotonachol or urecholine, up to 5 mg) and J3364 (injection, urokinase,
5000 iu vial), were packaged in CY 2007, proposed for separate payment
in CY 2008, but had final per day costs equal to or less than $60 based
on the updated ASPs and hospital claims data used for the CY 2008 final
rule with comment period. Therefore, in accordance with our
methodology, these two drugs will continue to be packaged in CY 2008.
In sections II.A.4.c.(5) and (6) of the CY 2008 OPPS/ASC proposed
rule, we proposed to package payment for all diagnostic
radiopharmaceuticals and contrast agents that would not otherwise be
packaged according to the proposed CY 2008 packaging threshold for
drugs, biologicals and radiopharmaceuticals. Tables 17 and 19 in
sections II.A.4.c.(5) and (6) of that proposed rule (72 FR 42671 and
42673 through 42674) listed the diagnostic radiopharmaceuticals and
contrast agents, respectively, that we proposed to package in CY 2008.
In section V.B.3.a.(4) of this final rule with comment period, we
discuss our CY 2008 policies for providing payment for diagnostic and
therapeutic radiopharmaceuticals.
We note that HCPCS code A9568 (Technetium Tc-99 arcitumomab,
diagnostic, per study dose, up to 45 millicuries) replaced HCPCS code
A9549 (Technetium Tc-99 arcitumomab, diagnostic, per study dose, up to
25 millicuries) beginning January 1, 2007. Our CY 2006 claims data
indicate that HCPCS code A9549 was billed an average of one time per
day. As we did not have claims data available for ratesetting purposes
for HCPCS code A9568, we estimated the number of units per day to also
be one.
3. Payment for Drugs and Biologicals 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 has
been established 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,'' known as SCODs.
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 SCODs 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.
In establishing the CY 2006 payment rates, 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
[[Page 66760]]
for 55 SCOD 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 OPPS 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's office
setting effective October 1, 2005, and updated claims data.
In our data analysis for the CY 2006 OPPS final rule with comment
period, we compared the payment rates for 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, we refer readers 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 with comment
period that payment rates derived from hospital claims data also
included acquisition and pharmacy handling costs because they are
derived directly from hospital charges (70 FR 68642). In CYs 2006 and
2007, we finalized a policy of providing payment to HOPDs for drugs,
biologicals, and associated pharmacy handling costs at a rate of ASP+6
percent. In addition, in CY 2006 we had proposed to collect pharmacy
overhead charge data via special pharmacy overhead HCPCS codes that
hospitals would report. We did not finalize this proposal for CY 2006
because of hospital concerns regarding the administrative burden
associated with reporting pharmacy overhead with these special HCPCS
codes (70 FR 68657 through 68665).
(2) Final Payment Policy
The provision in section 1833(t)(14)(A)(iii) of the Act, as
described above, continues to be applicable to determining payments for
SCODs for CY 2008. This provision requires that, in CY 2008, payment
for SCODs 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 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. In addition,
section 1833(t)(14)(E)(ii) authorizes the Secretary to adjust APC
weights for SCODs to take into account the MedPAC report relating to
overhead and related expenses, such as pharmacy services and handling
costs.
We considered several options for payment for drug acquisition
costs and pharmacy overhead for CY 2008 (72 FR 42735). First, we
considered proposing again the methodology we had proposed for CY 2006,
which involved the establishment of three drug overhead categories that
hospitals would use to report pharmacy overhead charges associated with
a drug provided in the HOPD. Until such data were available for
ratesetting purposes, we considered continuing our CY 2007 methodology
of bundling average hospital acquisition and pharmacy overhead
payments. While this approach has the advantage of not paying
separately for pharmacy overhead until we would have claims data on
which to establish separate payment rates for drug acquisition costs
and pharmacy overhead, its goal would still be to ultimately unpackage
OPPS payment for pharmacy overhead. We decided not to propose this
option because we believed and continue to believe that it is
undesirable to take steps that would ultimately lead to pharmacy
overhead being unpackaged at the same time that we have proposed
measures to expand packaging under the OPPS and have considered moving
toward more episode-based and encounter-based payment. Furthermore, we
note that as we considered this approach, we were mindful of the
comments we received in response to our CY 2006 proposed rule
expressing concern about the additional administrative burden on staff
and coders that this methodology might cause.
The second option we presented in the proposed rule was to continue
our CY 2007 methodology of providing a single bundled payment
representing average hospital acquisition costs and associated pharmacy
overhead costs. As stated previously, we believe that hospitals are
including pharmacy overhead costs in their charges for drugs,
consistent with MedPAC's findings. While we continue to believe that a
combined payment amount for drug acquisition costs and pharmacy
overhead based on our claims data is a reasonable methodology,
adequately accounts for acquisition costs and overhead, and is
consistent with our broader packaging efforts, we proposed a slight
variant of this approach for CY 2008 instead.
For CY 2008, we proposed to continue our methodology of providing a
combined payment rate for drug and biological acquisition costs and
pharmacy overhead. However, in addition, we proposed to instruct
hospitals to remove the pharmacy overhead charge from the charge for
the drug or biological and instead report the pharmacy overhead charge
on an uncoded revenue code line on the claim beginning in CY 2008. We
believed that this proposed change, from a CY 2007 policy where
hospitals include pharmacy overhead in their charges for the drug or
biological to a CY 2008 policy of including the pharmacy overhead
charges on an uncoded revenue code line, would allow us to package
pharmacy overhead costs for drugs and biologicals into payment for the
associated procedure, likely a drug administration procedure, in future
years when the CY 2008 claims data become available for ratesetting. We
proposed to apply this policy to the reporting of charges for all drugs
and biologicals, including contrast agents, irrespective of the item's
packaged or separately payable status for the CY 2008 OPPS. We did not
propose to apply this policy to the reporting of overhead charges for
radiopharmaceuticals, given the explicit instructions we gave hospitals
beginning in CY 2006 to include the charges for radiopharmaceutical
overhead and handling in the charges for the radiopharmaceutical
product.
We note that, in the case of current OPPS payment for packaged
drugs, payment for both the drugs and their associated pharmacy
overhead costs is already packaged into payment for the associated
separately payable
[[Page 66761]]
procedures, including drug administration services as discussed in
detail in section II.A.1.b.(2) of this final rule with comment period.
In addition, this methodology is consistent with the increased
packaging efforts discussed earlier in section II.A.4. of this final
rule with comment period. Because we would not expect to have claims
data reflecting these reporting changes until CY 2010, we proposed to
continue to provide a combined payment rate for acquisition costs and
pharmacy overhead for separately payable drugs and biologicals in CY
2008, similar to the combined payment rate provided in CYs 2006 and
2007 that represents the average hospital acquisition cost and pharmacy
overhead cost.
During the March 2007 APC Panel meeting, the APC Panel recommended
that CMS implement a three-phase plan to address OPPS payment for
pharmacy overhead costs. The first phase of the recommended plan
involves CMS working with interested stakeholders to develop a system
of defining pharmacy overhead categories for outpatient drugs that
require different levels of pharmacy resources. In addition, this phase
includes a provision recommending that CMS provide payment for pharmacy
overhead costs by setting payment rates for the developed categories
through New Technology APCs, presumably while collecting hospital cost
data on these services. The second phase of the recommended plan calls
for CMS to review estimates of pharmacy overhead costs as identified by
the GAO and MedPAC, and to consider external survey data from
stakeholders. The third and final phase of the recommended plan calls
for specific billing of pharmacy overhead costs using HCPCS codes
(corresponding to the categories developed in phase one, with payment
rates resulting from submitted hospital claims data) on the same claim
as a drug administration service. The APC Panel recommended that the
overhead payments be made in addition to the current 2007 ASP+6 percent
payment rates for separately payable drugs and biologicals that do not
have pass-through status.
During the September 2007 APC Panel meeting, the Panel recommended
that hospitals not be required to separately report charges for
pharmacy overhead and handling, and that pharmacy overhead and handling
costs be recognized within drug charges and paid through the packaged
or separate drug payment (as appropriate based on the drug packaging
threshold). In addition, the Panel recommended that we continue to
evaluate alternative methods to standardize the capture of pharmacy
overhead costs in a manner that is simple to implement at the
organizational level, similar to the three-phase approach recommended
by the Panel during the March 2007 meeting. We discuss our responses to
these recommendations below.
We received many public comments on our CY 2008 proposal to have
hospitals report charges for pharmacy overhead on uncoded revenue code
line. A summary of the public comments and our responses follow.
Comment: MedPAC supported the proposal to collect pharmacy overhead
data via uncoded revenue code lines because it would allow hospitals to
be paid more accurately for the variation in pharmacy overhead costs
when payment for those costs would be packaged into the costs of the
associated independent services. However, the vast majority of
commenters echoed the APC Panel's recommendation to not require
hospitals to separately report charges for pharmacy overhead and
handling and the Panel's further recommendation that pharmacy overhead
and handling costs be recognized within drug charges and be paid
through the packaged or separate drug payment (as appropriate based on
the drug packaging threshold). In general, the commenters cited
overwhelming implementation issues, including administrative reporting
burdens, challenges involved with identifying and splitting current
charges for drugs and biologicals into acquisition costs and overhead,
inflexible hospital accounting systems that are unable to combine and
differentiate charges depending on the insurer, complexity requiring
manual changes to individual claims, and beneficiary confusion
regarding these charges on their bills. In addition, some commenters
were concerned that secondary private insurers may not accept the
charges when the claim is submitted after being processed by Medicare.
The commenters noted that, due to these complex issues and the
relatively short timeframe in which hospitals would have to make these
changes, data obtained through this proposal are likely to be
unreliable.
A few commenters expressed disappointment that CMS did not propose
to adopt various methodologies they shared with CMS for capturing
pharmacy overhead data. Several commenters reiterated their proposals
for a three-phase system, similar to the three-phase plan recommended
by the APC Panel and discussed above. The commenters also suggested
that this plan could be altered, and that the survey contained in the
second phase survey could be replaced with direct adoption of median
costs from hospital claims data as long as prospective payments based
on claims data were not implemented prematurely.
One commenter suggested a modification to the current hospital cost
report by splitting the ``Pharmacy'' and ``Drugs Sold to Patient'' cost
centers into two lines each--one for drug acquisition costs and the
other for drug-related pharmacy and overhead costs. The commenters
stated that providers would then apportion their drug charges between
these two lines, and CMS would use the cost report to determine the
relative cost of pharmacy overhead to total drug costs.
Other commenters suggested that CMS conduct hospital surveys,
gather information through the fiscal intermediaries, or attach an
additional worksheet to the hospital cost report.
Several commenters requested that, if CMS were to finalize this
proposal, CMS should limit the reporting requirement to drugs with
significant pharmacy overhead and administrative costs.
In addition to these suggested methodologies, several commenters
expressed confusion regarding the phrases ``uncoded revenue code line''
and ``overhead and handling costs'' and requested clarification, while
others requested that, if CMS finalized the proposed policy for
pharmacy overhead services, CMS should delay the implementation date
and provide hospitals additional time to update their systems.
Response: We appreciate the commenters' many suggestions on ways to
collect hospital pharmacy data and the commenters' concerns regarding
our proposal. While we considered the APC Panel's March 2007
recommendation, as well as similar suggestions from other stakeholders,
we did not propose to adopt this recommendation (nor are we adopting
this recommendation in this final rule with comment period) to
implement a three-phase plan to address OPPS payment for pharmacy
overhead costs. For CY 2008, we proposed to expand packaging under the
OPPS by packaging payment for certain ancillary and supportive services
as discussed in section II.A.4.c. of this final rule with comment
period. Given our belief that packaging can be helpful in promoting
hospital efficiency and long-term cost containment and our belief that
pharmacy handling is ancillary and supportive to the administration of
drugs and biologicals in the HOPD, we do not believe it would be
desirable to take steps that would ultimately lead to payment for
pharmacy overhead costs being unpackaged under the OPPS.
[[Page 66762]]
As noted in the proposed rule (72 FR 42734 through 42735), the APC
Panel recommended that CMS establish separate payment amounts for
pharmacy overhead in addition to the current CY 2007 combined payment
for drug acquisition costs and pharmacy overhead of ASP+6 percent. As
we discussed in the CY 2006 OPPS final rule with comment period (70 FR
68657) and in the CY 2007 OPPS/ASC final rule with comment period (71
FR 68089 through 68092), 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. We continue
to believe that our payment rates for drug acquisition costs and
pharmacy overhead should be determined based on the costs reflected in
our claims data, as these costs reflect both acquisition costs and
overhead costs. We also believe that establishing additional payment
for pharmacy overhead beyond our proposed payment rates based on claims
data would distort the relative relationship of costs across HOPD
services, which is the basis of the OPPS. As we do consider the Panel's
March 2007 recommendation to be aligned with the current OPPS trend
towards increasing the size of payment bundles, we are accepting the
Panel's September 2007 recommendation to continue to evaluate alternate
methods to standardize the capture of pharmacy overhead costs in a
manner that is simple to implement at the organizational level. As
such, we are interested in continuing our dialogue with hospital
stakeholders regarding the issue of pharmacy overhead. We generally
accept requests from interested organizations to discuss their views
about OPPS payment policy issues, including pharmacy handling issues.
In addition, we establish the OPPS rates through regulations and, as
such, 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 payment for the forthcoming year.
After reviewing the public comments we received on the CY 2008
proposal, we have a better understanding of the scope of our proposal
and the burden that it would have on hospitals. While we continue to
believe that packaging pharmacy overhead costs into the associated
independent procedures for administration of the drugs could pay
hospitals more appropriately for the variable pharmacy overhead costs
associated with different types of drugs, we are concerned about the
operational challenges and administrative burdens that hospitals would
face in reporting drugs provided in the HOPD. Therefore, we are not
finalizing our proposal to require hospitals to remove pharmacy
overhead costs from drug acquisition costs and to report pharmacy
overhead costs in an uncoded revenue code line.
We appreciate the suggestions to implement a hospital survey or to
include a pharmacy overhead worksheet on the hospital cost report.
However, we do not believe that it would be administratively feasible
or reasonable from a resource perspective to develop and update
information regarding pharmacy overhead costs through either of these
methodologies. Presumably the commenters believe that, by collecting
these data, we would provide additional separate payments to hospitals
for pharmacy overhead services. As explained above, separate payment
for pharmacy overhead would decrease the current size of the drug
payment bundles and would not be aligned with the additional packaging
we have implemented in this final rule with comment period.
In addition, several commenters expressed their preference to
retain the pharmacy overhead payment packaged with the payment for the
drug, stating that this is the most logical and appropriate grouping
for payment purposes. We agree with these commenters and believe that a
single OPPS payment that represents both drug acquisition and
associated pharmacy overhead costs is the most reasonable and logical
method of payment for these services. Therefore, we are adopting the
September 2007 recommendation of the APC Panel that pharmacy overhead
and handling costs be recognized within drug charges and be paid
through the packaged or separate drug payment (as appropriate based on
the drug packaging threshold). We do not believe that we need to
provide specific guidance on the elements of pharmacy handling and
overhead that hospitals should consider in setting their charges for
drugs, because, as MedPAC found and many commenters confirmed,
hospitals are currently including the costs of pharmacy overhead in
their charges for drugs and biologicals.
After consideration of the public comments received, we are
finalizing our proposal to provide a single bundled payment for
separately payable drugs and biologicals, inclusive of both drug
acquisition and pharmacy overhead costs. Hospitals should continue to
consider the costs of pharmacy overhead in developing and reporting
their charges for drugs and biologicals, maintaining their current
practice.
For the CY 2008 OPPS/ASC proposed rule, we evaluated two data
sources that we have available to us for setting the CY 2008 payment
rates for drugs and biologicals. The first source of drug pricing
information that we have is the ASP data from the fourth quarter of CY
2006, which were used to set payment rates for drugs and biologicals in
the physician's office setting, effective April 1, 2007. We have ASP-
based prices for approximately 500 drugs and biologicals (including
contrast agents) payable under the OPPS. However, we currently do not
have any ASP data on radiopharmaceuticals.
The second source of cost data that we have for drugs, biologicals,
and radiopharmaceuticals is the mean and median costs derived from the
CY 2006 hospital claims data. As section 1833(t)(14)(A)(iii) of the Act
clearly specifies that payment for SCODs in CY 2008 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,
instead of using median costs.
In our data analysis, we compared the payment rates for drugs and
biologicals using data from both sources described above. After
determining the proposed CY 2008 packaging status of drugs and
biologicals, we estimated aggregate expenditures for all drugs and
biologicals (excluding radiopharmaceuticals) that would be separately
payable in CY 2008 using mean costs from the hospital claims data and
the ASP-based payment amounts, and calculated the equivalent average
ASP-based payment amount under both payment methodologies.
The results of our proposed rule data analysis for the proposed
rule indicated that using mean unit cost to set the payment rates for
the drugs and biologicals that would be separately payable in CY 2008
would be equivalent to basing their payment rates, on average, at ASP+5
percent. Therefore, we proposed to continue to provide a bundled
payment for the acquisition costs of drugs and biologicals and the
associated pharmacy overhead in CY 2008 at ASP+5 percent, where the ASP
add-on percent was calculated based on mean costs from hospital claims
data. In addition, as described in section II.A.4.c.(6) of this final
rule with comment period, for contrast agents, we proposed a
supplemental approach that would package payment for all contrast media
under the CY 2008 OPPS.
[[Page 66763]]
During the September 2007 meeting of the APC Panel, the Panel
recommended that we continue to provide payment for separately payable
drugs at a rate of ASP+6 percent for CY 2008. We discuss our response
to this recommendation below.
We received many public comments on our proposal to pay for
separately payable drugs and biologicals and their pharmacy overhead at
ASP+5 percent in CY 2008. A summary of the public comments and our
responses follow.
Comment: Many commenters agreed with the Panel's recommendation to
continue providing payment for separately payable drugs, including
several specific groups of drugs such as blood clotting factors and
IVIG, at ASP+6 percent. Some commenters noted that this would eliminate
a site-of-service differential that would otherwise exist between the
hospital outpatient and physicians' office settings if HOPDs were paid
at ASP+5 percent while physicians' offices were paid at ASP+6 percent.
The commenters also cited issues of charge compression. Specifically,
the commenters explained that many lower cost packaged drugs have a
higher markup and the relative ASP number is not inclusive of this
pricing practice because only separately payable drugs are used in the
comparison. A few commenters also noted that CMS has not demonstrated
that concerns that led to a continuation of the ASP+6 percent
methodology in CY 2007, such as a limited understanding of pharmacy
overhead costs and their relationship to hospital outpatient drugs,
have been resolved. Finally, some commenters expressed concern that,
even at ASP+6 percent, hospitals may not be receiving adequate payments
to account for both acquisition costs and overhead costs. Furthermore,
some of these commenters requested payment increases for certain groups
of drugs, such as IVIG and blood products.
Response: In analyzing data for the CY 2008 final rule with comment
period, we again performed the analysis described in the CY 2008
proposed rule by 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 equivalent
average ASP-based payment rate for drugs and biologicals provided in
HOPDs for CY 2008. As we did for our final rule analysis to determine
the final packaging status for each drug, we used updated CY 2006 mean
unit costs and drug volumes and updated ASP data. The result of our
final analysis using updated hospital claims data for the full CY 2006
year and updated CCRs is that the equivalent average ASP-based payment
amount for separately payable drugs and biologicals, including pharmacy
handling costs, is equal to ASP+3 percent for CY 2008. Therefore,
according to our CY 2008 proposal for payment of separately payable
drugs and biologicals which includes pharmacy overhead payment, based
on mean costs from CY 2006 hospital claims, the OPPS payment rate for
separately payable drugs and biologicals would be ASP+3 percent.
We acknowledge that different payment rates for drugs and
biologicals provided in the physician's office and HOPD settings are of
concern to some commenters. However, the OPPS, the MPFS physician's
office payments for services and physician's office payments for Part B
drugs are based on very different payment methodologies. In particular,
the OPPS relies upon costs from the most updated claims and Medicare
cost report data to develop payment rates. On the other hand, the MPFS
pays for services based on estimates of input costs and pays for drugs
and biologicals at ASP+6 percent, as required by statute. Therefore, it
is not surprising to us that the estimated costs of drug and
biologicals and their associated pharmacy overhead, like many other
OPPS services, could be different in the HOPD than in the physician's
office, resulting in different payments in the two settings. We do not
believe that different payment rates for drugs and biologicals in the
HOPD or physician's office settings will create problems for
beneficiaries regarding access to drug administration services because
we have not seen problems with access in the two settings for other
types of services, including diagnostic studies, surgical procedures,
and visits, which generally have different payment rates under the two
payment systems (unless there is an applicable externally applied
statutory cap to payment, such as the cap on payment for imaging
services provided in the physician's office based on the OPPS rates).
In response to the commenters' concerns regarding the effects of
charge compression on drug payment, as described further in section
II.A.1.c. of this final rule with comment period, we have contracted
with RTI to estimate regression-based CCRs using charge data from both
inpatient and outpatient claims for hospital ancillary departments. We
will consider whether it would be appropriate to adopt regression-based
CCRs for the OPPS in the future after we receive RTI's comprehensive
review of the OPPS cost estimation methodology and review the results
of the use of both inpatient and outpatient charges across all payers
to reestimate regression-based CCRs.
After a period of continuing ASP+6 percent payment in CY 2007 while
we gathered additional information regarding pharmacy overhead costs,
we believe that it is most appropriate at this point to continue to pay
for drugs and biologicals and their associated pharmacy overhead costs
using an ASP-based system, but to determine the relative ASP percent
based on mean costs from claims rather than continue to use ASP+6
percent. Therefore, we are not accepting the recommendation of the APC
Panel to continue to pay for separately payable drugs and biologicals
at ASP+6 percent for CY 2008. After reviewing the commenters' responses
to our CY 2008 proposal, we are reassured that hospitals currently
capture pharmacy overhead costs in their charges for drugs, and we have
clear guidance from the APC Panel and some commenters that pharmacy
overhead and handling costs should continue to be recognized within
drug charges and paid through the drug payment.
Our claims data for the CY 2007 and CY 2008 final rules
consistently have shown equivalent average ASP-based amounts for
separately payable drugs and biologicals that are lower than ASP+6
percent, specifically ASP+4 percent and APC+3 percent, respectively.
However, because we have been paying ASP+6 percent for separately
payable drugs and biologicals under the OPPS for the last 2 years, we
believe it is appropriate to transition to the use of hospital claims
data as the basis for the relative ASP percent. Therefore, we will
provide a 2-year transition, with a one year transitional payment rate
in CY 2008, and pay for separately payable drugs and biologicals and
associated pharmacy overhead based on a 50/50 blend of their CY 2007
payment rate of ASP+6 percent and their final CY 2008 equivalent
average ASP-based payment amount of ASP+3 percent. This blend results
in a payment amount of ASP+4.5 percent. However, because we pay based
on whole percentages in relation to ASP, we are rounding the blend to
ASP+5 percent for CY 2008. In summary, we will provide a transitional
payment of ASP+5 percent for separately payable drugs and biologicals
and associated pharmacy overhead in CY 2008 as we move toward a
relative ASP percent based on mean costs from claims for CY 2009.
Comment: Several commenters disagreed with our calculation of an
average ASP-based payment amount for drugs and biologicals and
associated
[[Page 66764]]
pharmacy overhead costs based on aggregate costs from claims. One
commenter stated that instead of an aggregate amount across all drugs,
each drug should be individually examined in order to determine average
hospital acquisition cost. This commenter noted that, by aggregating
drug costs across all separately paid drugs to determine the equivalent
average ASP-based payment rate, some drugs could be underpaid while
others could be overpaid. Other commenters suggested that CMS include
relatively inexpensive drugs, including drugs that are usually packaged
as well as drugs that may not have their own HCPCS codes but are
reported with charges on uncoded revenue code lines. The commenters
noted that, because of charge compression and hospital billing
practices, these drugs typically receive the highest markups because
they are relatively inexpensive. Other commenters recommended that CMS
include packaged drugs with HCPCS codes that are currently packaged in
determining the average ASP-based amount. The commenters noted that if
all drugs were paid separately in the HOPD, there would be better
representation of pharmacy overhead costs associated with lower cost
drugs in the average ASP-based amount calculated. The commenters
explained that hospitals often attribute higher markups to lower cost
drugs and lower markups to higher cost drugs, an issue known as charge
compression. By providing separate payment for all drugs, the OPPS
would then consider the full set of Part B drugs and their associated
overhead as part of the average ASP-based amount, rather than relying
on only separately paid, and therefore more expensive, drugs to perform
this calculation. The commenters claimed that this change would more
accurately account for the actual pharmacy overhead charges that
hospitals have built into their accounting systems, and, as a result,
the equivalent average ASP-based amount would be higher. A few
commenters expressed concern that ASP reflects prices and discounts not
passed along to providers and that ASP is a measure of sales to all
entities, not just hospitals. Other commenters noted that the two
quarter lag in updated ASP data is problematic for hospitals that
experience varying purchasing conditions from quarter to quarter.
Response: We continue to believe that use of ASP as a payment
methodology is appropriate under the OPPS because these rates are
updated quarterly and are therefore more reflective of current market
conditions that influence hospital purchasing prices than hospital
claims data. 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. While we understand that, by aggregating the
costs of separately payable drugs and biologicals prior to developing
an equivalent average ASP-based payment rate, the result could be that
some drugs could be relatively underpaid in a given clinical scenario
while others could be relatively overpaid, we continue to believe that
ASP data are our best proxy for average hospital acquisition costs
under the OPPS and that the calculation should be performed using
aggregated drug costs. Given the information provided by commenters
regarding hospitals' diverse charging practices and the differential
inclusion of pharmacy overhead costs in charges for low and high cost
drugs, we do not believe that it would be reasonable to conduct this
comparison on a drug-specific level to calculate a distinct equivalent
ASP-based payment for each drug under the OPPS that would reflect the
acquisition and overhead costs of that particular drug. Instead, we
continue to believe that it is more appropriate to develop an
equivalent average ASP-based payment rate that determines the ASP add-
on percent based on the aggregated hospital costs of separately payable
drugs and biologicals calculated from claims data, recognizing that the
OPPS is a system based on the averaging of costs for services.
In addition, we do not include packaged drugs and biologicals in
this analysis because cost data for these items are already accounted
for within the APC ratesetting process through the median cost
calculation methodology discussed in section II.A.2. of this final rule
with comment period. To include the costs of packaged drugs in both our
APC ratesetting process (for associated procedures present on the same
claim) and in our ratesetting process to establish a relative ASP-based
payment amount for drugs and biologicals would give these data
disproportionate emphasis in the OPPS system by skewing our analyses,
as the costs of these packaged items would be, in effect, counted
twice. 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.
As noted in the CY 2007 OPPS final rule with comment period, 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. We
believe that updating drug payment rates quarterly based on the most
currently available ASP, given that ASP data include sales to hospitals
in addition to others, provides the most up-to-date payment possible
that is reflective of contemporary market trends and hospital
acquisition costs.
Comment: One commenter requested that CMS create a HCPCS J-code for
tositumomab, currently provided under a radioimmunotherapy regimen and
billed as part of HCPCS code G3001 (Administration and supply of
tositumomab, 450 mg). The commenter argued that because tositumomab is
listed in compendia, is approved by the FDA as part of the
BEXXAR[supreg] regimen, and has its own National Drug Code (NDC)
number, it should be recognized as a drug and, therefore, paid as other
drugs are paid under the OPPS methodology instead of having a payment
rate determined by hospital claims data. The commenter suggested that a
payment rate could be established using the ASP methodology.
Response: As we have noted in the November 10, 2005 final rule with
comment period for CY 2006 (70 FR 68654) and the November 7, 2003 final
rule with comment period for CY 2004 (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 radioimmunotherapy
treatment regiment. 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. Specifically, administration of unlabeled tositumomab
is a complete service that qualifies for separate payment under its own
clinical APC. This complete service is currently described by HCPCS
code G3001. Therefore, we do not agree with the commenter's
recommendation that we should assign a separate HCPCS code to
[[Page 66765]]
the supply of unlabeled tositumomab. Rather, we will continue to make
separate payment for the administration of tositumomab, and payment for
the supply of unlabeled tositumomab is packaged into the administration
payment.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal with a modification to provide a 2-year
transition for payment for separately payable drugs and biologicals
under the OPPS based on the equivalent average ASP-based payment amount
calculated from aggregate costs from hospitals claims. While the
payment amount without a transition would be ASP+3 percent for CY 2008,
we will be providing a transitional payment of ASP+5 percent for these
products in CY 2008.
(3) Payment for Blood Clotting Factors
For CY 2007, we are providing payment for blood clotting factors
under the OPPS at ASP+6 percent, plus an additional payment for the
furnishing fee that is also a part of the payment for blood clotting
factors furnished in physicians' offices under Medicare Part B. The CY
2007 updated furnishing fee is $0.152 per unit.
For the CY 2008 OPPS, we proposed to pay for blood clotting factors
at ASP+5 percent and to continue our policy for payment of the
furnishing fee using the updated amount for CY 2008. For CY 2008, the
furnishing fee increases by 4.0 percent to $0.158.
As indicated in the CY 2008 OPPS/ASC proposed rule (72 FR 42736),
we have consistently noted that we would update the payment amount for
the furnishing fee each year (based on the Consumer Price Index (CPI))
so that the payment amount for the furnishing fee is equal to the
furnishing fee payment amount noted in the MPFS final rule. As
discussed in greater detail in the CY 2008 MPFS proposed rule (72 FR
38152), the CPI data for the 12-month period ending in June 2007 were
not available when we developed the OPPS and the MPFS proposed rules.
Because the furnishing fee update is based on the percentage
increase in the CPI for medical care for the 12-month period ending
with June of the previous year and the Bureau of Labor Statistics
releases the applicable CPI data after the OPPS and MPFS proposed rules
are published, we have not been able to include the actual updated
furnishing fee in the CY 2006 through CY 2008 OPPS and MPFS proposed
rules. Rather, we announced in these proposed rules that we intended to
include the actual figure for the percent change in the applicable CPI,
and the updated furnishing fee calculated based on that figure, in the
associated final rule. Given the timing of the availability of the
applicable data and our timeframe for preparing proposed rules, this
process is unavoidable and likely to remain unchanged in the future. We
believed that including a discussion of the furnishing fee update in
annual rulemaking does not provide an advantage over other means of
announcing this information, so long as the current statutory update
methodology continues in effect. We believed that the public's need for
information and adequate notice regarding the updated furnishing fee
could be better met by issuing program instructions which would
eliminate the discussion of the furnishing fee update annually in
rulemaking. In addition, by communicating the updated furnishing fee in
program instructions, the actual figure for the percent change in the
applicable CPI and the updated furnishing fee calculated based on that
figure could be announced more timely than when included as part of the
annual rulemaking process. Because the furnishing fee update process is
statutorily determined and is based on an index that is not affected by
administrative discretion or public comment, we do not believe our
proposed means of communicating the update would adversely affect
stakeholders or the public. Therefore, for CY 2009 and thereafter,
until such time as the update methodology may be modified, we proposed
to announce the blood clotting factor furnishing fee using applicable
program instructions and posting on the CMS Web site.
We received a few public comments on our proposal for the blood
clotting factor furnishing fee. A summary of the public comments and
our responses follow.
Comment: Several commenters supported our proposal to announce the
blood clotting factor furnishing fee using program instructions. The
commenters agreed that, by communicating the updated furnishing fee in
program instructions, the actual figure for the percent change in the
applicable CPI and the updated furnishing fee calculated based on that
figure could be announced more timely. To that end, the commenters also
suggested that CMS post this information on the CMS Web site.
Response: We appreciate the support of these commenters for our
proposal. We believe that program instructions allow additional
flexibility regarding the announcement of the blood clotting factor
furnishing fee. Therefore, we are finalizing the proposal, without
modification, and in future years we will announce the updated blood
clotting factor furnishing fee using applicable program instructions
and posting on the CMS Web site. (We refer readers to the CY 2008 MPFS
final rule for further discussion of this issue.)
(4) Payment for Radiopharmaceuticals
(a) Background
Section 303(h) of Pub. L. 108-173 exempted radiopharmaceuticals
from ASP pricing in the physician's office setting. Beginning in the CY
2005 OPPS final rule with comment period, we have exempted
radiopharmaceutical manufacturers from reporting ASP data for payment
purposes under the OPPS (for more information, we refer readers to the
CY 2005 OPPS final rule with comment period and the CY 2006 OPPS final
rule with comment period, 69 FR 65811 and 70 FR 68655, respectively).
Consequently, we did not have ASP data for radiopharmaceuticals for
consideration for CY 2008 OPPS ratesetting. In accordance with section
1833(t)(14)(B)(i)(I) of the Act, we have classified
radiopharmaceuticals under the OPPS as SCODs. As such, we have paid for
radiopharmaceuticals 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, discussed earlier in this final
rule with comment period.
For CYs 2006 and 2007, we used mean unit cost data from hospital
claims to determine each radiopharmaceutical's packaging status and
implemented a 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 CCR.
This methodology was finalized as an interim proxy for average
acquisition cost because of the unique circumstances associated with
providing radiopharmaceutical products to Medicare beneficiaries. The
single OPPS payment represented Medicare payment for both the
acquisition cost of the radiopharmaceutical and its associated pharmacy
overhead costs. We clearly stated in both the CY 2006 and CY 2007 OPPS/
ASC final rules with comment period that we did not intend to maintain
this methodology permanently (70 FR 68656 and 71 FR 68096,
respectively), and that we would
[[Page 66766]]
continue to actively seek other methodologies for setting payments for
radiopharmaceuticals in future years.
During the CY 2006 and CY 2007 rulemaking processes, we encouraged
hospitals and the radiopharmaceutical stakeholders to assist us in
developing a viable long-term prospective payment methodology for these
products under the OPPS. As discussed in the CY 2008 proposed rule, we
are pleased to note that we have had many discussions over this past
year with interested parties regarding the availability and limitations
of radiopharmaceutical cost data. In addition, we have received several
suggestions from interested parties on how to structure future payment
methodologies. Many of the proposals we have received have suggested
that we consider differentiating radiopharmaceutical products into two
different categories by cost, at least in part because stakeholders
have speculated that charge compression leads to inappropriately low
calculated costs for expensive radiopharmaceuticals. For CY 2008, we
made separate payment proposals for diagnostic radiopharmaceuticals and
therapeutic radiopharmaceuticals. While we have not grouped
radiopharmaceuticals based on cost, we note that the therapeutic
radiopharmaceuticals typically are more expensive than the diagnostic
radiopharmaceuticals. We identified all diagnostic radiopharmaceuticals
specifically as those Level II HCPCS codes that include the term
``diagnostic'' along with a radiopharmaceutical in their long code
descriptors. Therefore, we were able to distinguish therapeutic
radiopharmaceuticals from diagnostic radiopharmaceuticals as those
Level II HCPCS codes that have the term ``therapeutic'' along with a
radiopharmaceutical in their long code descriptors. We note that all
radiopharmaceutical products fall into one category or the other; their
use as a diagnostic radiopharmaceutical or therapeutic
radiopharmaceutical is mutually exclusive.
(b) Payment for Diagnostic Radiopharmaceuticals
As discussed in section II.A.4.c.(5) and (6) of the CY 2008 OPPS/
ASC proposed rule, we proposed to package payment for diagnostic
radiopharmaceuticals and contrast agents with per day costs over $60 as
part of our packaging proposal for CY 2008. Radiopharmaceuticals and
contrast agents currently are included as SCODs in section
1833(t)(14)(B) of the Act, and we currently package payment for
diagnostic radiopharmaceuticals and contrast agents with per day costs
of $55 or less. However, our proposal for CY 2008 also included
packaging payment for all diagnostic radiopharmaceuticals and contrast
agents, regardless of their per day cost. Packaging costs into a single
aggregate payment for a service, encounter, 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.
The proportion of drugs, biologicals, and radiopharmaceuticals that are
separately paid has increased in recent years, from 30 percent of HCPCS
codes for these products in CY 2003 to 50 percent in CY 2007, a pattern
that has been noted previously for procedural services as well. Our
proposal to package payment for diagnostic radiopharmaceuticals and
contrast agents regardless of per day cost furthers the fundamental
principles of a prospective payment system.
In the proposed rule, we stated our belief that our proposed
treatment of diagnostic radiopharmaceuticals and contrast agents
differently from other SCODs was appropriate for several reasons.
First, the statutory requirement that we must pay separately for drugs
and biologicals for which the per day cost exceeds $50 under section
1833(t)(16)(B) of the Act has expired. Therefore, we are not restricted
to the extent to which we can package payment for SCODs and other
drugs, nor are we required to treat all classes of drugs in the same
manner with regard to whether they are packaged or separately paid. We
have used this flexibility to make different packaging determinations
for several years with regard to specific anti-emetic drugs. While we
proposed to continue to establish an updated cost threshold for
packaging drugs, biologicals, and radiopharmaceuticals, we also
proposed an approach specific to diagnostic radiopharmaceuticals and
contrast agents that would otherwise be separately paid.
Second, diagnostic radiopharmaceuticals and contrast agents
function effectively as supplies that enable the provision of an
independent service. More specifically, contrast agents are always
provided in support of a diagnostic or therapeutic procedure that
involves imaging, and diagnostic radiopharmaceuticals are always
provided in support of a diagnostic nuclear medicine scan. This is
different from many other SCODs, for example, therapeutic
radiopharmaceuticals, where the therapeutic radiopharmaceutical itself
is the primary therapeutic modality. Given the inherent function of
contrast agents and diagnostic radiopharmaceuticals as supportive to
the performance of an independent procedure, we view the packaging of
payment for contrast agents and diagnostic radiopharmaceuticals as a
logical initial step to expand packaging for SCODs. As we consider
moving to additional encounter-based and episode-based payment in
future years, we may consider additional options for packaging more
SCODs in the future.
Third, section 1833(t)(14)(A)(iii) of the Act requires that payment
for SCODs be set prospectively based on a measure of average hospital
acquisition cost. While we have ASP data for contrast agents, the lack
of ASP data as a source of average acquisition cost for
radiopharmaceuticals and the varying inclusion of overhead and handling
costs in the charge for a radiopharmaceutical resulted in payment for
radiopharmaceuticals at charges reduced to cost on a temporary basis
for CYs 2006 and 2007.
We now believe our claims data offer an acceptable proxy for
average hospital acquisition cost and associated handling and
preparation costs for radiopharmaceuticals. We believe that hospitals
have adapted to the CY 2006 coding changes for radiopharmaceuticals and
responded to our instructions to include charges for
radiopharmaceutical handling in their charges for the
radiopharmaceutical products. We have relied on mean unit costs derived
from our claims data as one proxy for average acquisition cost and
pharmacy overhead, and we use these data to determine the packaging
status for SCODs. However, in light of improved data for
radiopharmaceuticals in the CY 2006 claims, we believed that the line-
item estimated cost for a diagnostic radiopharmaceutical in our claims
data is a reasonable approximation of average acquisition and
preparation and handling costs for diagnostic radiopharmaceuticals.
Further, because the standard OPPS packaging methodology packages the
total estimated cost for each radiopharmaceutical on each claim
(including the full range of costs observed on the claims) with the
cost of associated nuclear medicine procedures for ratesetting, this
packaging approach is consistent with considering the average cost for
radiopharmaceuticals, rather than the median. We also noted our belief
that our improved claims data
[[Page 66767]]
could support the establishment of separate, prospective payment rates
for diagnostic radiopharmaceuticals with per day costs exceeding our
general packaging threshold (analogous to our proposal for therapeutic
radiopharmaceuticals). However, we proposed to package all diagnostic
radiopharmaceuticals because we believed additional packaging of
payment for supportive and ancillary services, including diagnostic
radiopharmaceuticals, would provide additional incentives for
efficiency and greater flexibility for hospitals to manage their
resources.
In the case of contrast agents, while we have ASP data that can be
a proxy for average hospital acquisition cost and associated handling
and preparation costs, payment for almost all contrast agents would be
packaged under the OPPS for CY 2008 based on the $60 per day packaging
threshold. Therefore, as discussed in more detail in section
V.B.3.a.(4) of this final rule with comment period, we believed it
would be most appropriate to package payment for all contrast agents
for CY 2008, to better provide for accurate payment for the associated
tests and procedures that promotes hospital efficiency.
In summary, in the context of our CY 2008 proposal, we viewed
diagnostic radiopharmaceuticals and contrast agents as ancillary and
supportive of the diagnostic tests and therapeutic procedures in which
they are used. In light of our authority to make different packaging
determinations, and the improved reporting of hospital charges for
radiopharmaceutical handling in the CY 2006 claims data, we proposed to
package payment for contrast agents and diagnostic radiopharmaceuticals
for CY 2008.
For more information on how rates were set for procedures in which
diagnostic radiopharmaceuticals or contrast agents are used, and for a
further discussion regarding our final packaging methodology for CY
2008, we refer readers to section II.B. of this final rule with comment
period.
During its March 2007 meeting, the APC Panel made a recommendation
that CMS work with stakeholders on issues related to payment for
radiopharmaceuticals, including evaluating claims data for different
classes of radiopharmaceuticals and ensuring that a nuclear medicine
procedure claim always includes at least one reported
radiopharmaceutical agent. As discussed in section II.A.4.c.(5) of the
proposed rule, we proposed to accept the APC Panel's recommendation,
and we welcomed public comment on the burden hospitals would experience
should we require such precise reporting. We also solicited comment
specifically on the importance of such a requirement in light of our
discussion in the proposed rule on the representation of
radiopharmaceuticals in the single claims for diagnostic nuclear
medicine procedures, the presence of uncoded revenue code charges
specific to diagnostic radiopharmaceuticals on claims without a coded
radiopharmaceutical, and our proposal to package payment for all
diagnostic radiopharmaceuticals for CY 2008. A summary of the public
comments we received on this issue, our responses, and our response to
the APC Panel recommendation can be found in section II.A.4.c.(5) of
this final rule with comment period.
We received many comments on our proposal to package payment for
all diagnostic radiopharmaceuticals and contrast agents for CY 2008. A
summary of the public comments and our responses follow.
Comment: A number of commenters stated that diagnostic
radiopharmaceuticals and contrast agents with per day costs over the
proposed OPPS drug packaging threshold are defined as SCODs and,
therefore, should be assigned separate APC payments. In particular, the
commenters questioned CMS's authority to classify groups of drugs, such
as diagnostic radiopharmaceuticals and contrast agents, and implement
packaging and payment policies that do not reflect their status as
SCODs. In addition, the commenters objected to the proposal to package
payment for diagnostic radiopharmaceuticals and contrast agents
because, as SCODs, the commenters believed these products were required
by statute to be paid at average acquisition cost. The commenters
explained that, when several different diagnostic radiopharmaceuticals
or contrast agents may be used for a particular procedure, the costs of
these diagnostic radiopharmaceuticals or contrast agents are averaged
together and added to the amount for the procedure in order to
determine the payment rate for the associated procedural APC.
Therefore, the commenters argued that the amount added to the procedure
cost through packaging, representing the cost of the diagnostic
radiopharmaceutical or contrast agent, does not reflect the average
acquisition cost of any one particular item but, rather, reflects the
average cost of whatever items may be used with that particular
procedure.
Response: As discussed above, we based our proposal to treat
diagnostic radiopharmaceuticals and contrast agents differently from
other SCODs upon our reasoning that the statutorily required OPPS drug
packaging threshold has expired and our view that diagnostic
radiopharmaceuticals and contrast agents function effectively as
supplies that enable the provision of an independent service, rather
than serving themselves as the therapeutic modality. We sought to
package their payment as ancillary and supportive services in order to
provide incentives for greater efficiency and to provide hospitals with
additional flexibility in managing their resources. We note that we
currently classify different groups of drugs for specific payment
purposes, as evidenced by our policy regarding the oral and injectable
forms of the 5HT3 anti-emetics and our fixed price drug packaging
threshold.
Although our final CY 2008 policy, as described in section
II.A.4.c.(5) and (6) of this final rule with comment period, packages
payment for all diagnostic radiopharmaceuticals and contrast agents
into the payment for their associated procedures, we will continue to
provide payment for these items in CY 2008 based on a proxy for average
acquisition cost. We believe that the line-item estimated cost for a
diagnostic radiopharmaceutical in our claims data is a reasonable
approximation of average acquisition and preparation and handling costs
for diagnostic radiopharmaceuticals. Further, because the standard OPPS
packaging methodology packages the total estimated cost for each
radiopharmaceutical on each claim (including the full range of costs
observed on the claims) with the cost of associated nuclear medicine
procedures for rate setting, this packaging approach is consistent with
considering the average cost for radiopharmaceuticals, rather than the
median cost.
We further note that these drugs, biologicals, or
radiopharmaceuticals for which we have not established a separate APC
and, therefore, for which payment would be packaged rather than
separately provided under the OPPS, could be considered to not be
SCODs. Similarly, drugs, biologicals, and therapeutic
radiopharmaceuticals with mean per day costs of less than $60 that are
packaged and for which a separate APC has not been established would
also not be SCODs. This reading is consistent with our final payment
policy whereby we package payment for diagnostic radiopharmaceuticals
and contrast agents and provide payment for these products through
payment for their associated procedures.
Comment: A few commenters suggested that CMS misclassified
[[Page 66768]]
HCPCS codes A9542 (Indium In-111 ibritumomab tiuxetan, diagnostic, per
study dose, up to 5 millicuries) and A9544 (Iodine I-131 tositumomab,
diagnostic, per study dose) as ``diagnostic'' radiopharmaceuticals. The
commenters explained that these are radiopharmaceutical products that
are used as part of a therapeutic regimen and, therefore, should be
considered therapeutic for OPPS payment purposes.
Response: As discussed above, for the proposed rule, we classified
each radiopharmaceutical into one of two groups according to whether
its long descriptor contained the term ``diagnostic'' or
``therapeutic.'' HCPCS codes A9542 and A9544 both contain the term
``diagnostic'' in their long code descriptors. Therefore, according to
this methodology, we classified them as diagnostic for the purposes of
OPPS payment. While we understand that these items are provided in
conjunction with additional supplies, imaging tests, and therapeutic
radiopharmaceuticals for patients already diagnosed with cancer, we
continue to believe that the purpose of HCPCS codes A9542 and A9544 is
diagnostic in nature. While the group of services may be considered a
therapeutic regimen by the commenters, HCPCS codes A9542 and A9544 are
provided in conjunction with a series of imaging scans. Many nuclear
medicine studies using diagnostic radiopharmaceuticals are provided to
patients who already have an established diagnosis. We would not
consider HCPCS codes A9542 and A9544 to be therapeutic because these
items are provided immediately prior to the furnishing of a diagnostic
imaging procedure, and are used to identify the proper dose of the
therapeutic agent at a later date.
Comment: One commenter requested that CMS reassign the dosage
descriptor for HCPCS code A9524 (Iodine I-131 iodinated serum albumin,
diagnostic, per 5 microcuries) to reflect the usual package size of
this item. The commenter noted that there is only one manufacturer for
this product, and it is only available in a single-unit, single-use,
calibrated dose of 25 microcuries. The commenter claimed that many
hospitals have been mistakenly billing one unit for this product,
instead of correctly billing five units. Therefore, the commenter
requested that the dosage descriptor reflect the single-unit, single-
use, calibrated 25 microcurie dose.
Response: As we discussed in the CY 2008 proposed rule, at its
March 2007 meeting, the APC Panel recommended that we consider the use
of external data and work with stakeholders to determine the correct
code descriptor units for each radiopharmaceutical, including HCPCS
code A9524. As stated in the proposed rule (72 FR 42741), we appreciate
the APC Panel's recommendation. We are always open to meeting with
interested stakeholders and examining any data they may provide to us.
However, we were unable to accept the APC Panel's recommendation
concerning the development of specific code descriptors because
decisions regarding the creation of permanent Level II HCPCS codes,
including code descriptors, are coordinated by the CMS HCPCS Workgroup
and are outside the scope of the OPPS. For further information on the
HCPCS coding process, we refer readers to the CMS Web site at: http://www.cms.hhs.gov/MedHCPCSGenInfo/01--Overview.asp#TopOfPage. We
encouraged interested parties to submit requests for revisions of code
descriptors to the CMS HCPCS Workgroup for its consideration.
We have learned that the commenter requested the CMS HCPCS
Workgroup to change the descriptor for HCPCS code A9524 to more
accurately reflect the dosing of this product. However, the CMS HCPCS
Workgroup, under its authority and responsibility to create and
maintain Level II HCPCS codes and their descriptors, has decided to
retain the current descriptor that includes the ``per 5 microcuries''
dosage descriptor. Therefore, hospitals are reminded to ensure that
units of drugs, biologicals, and radiopharmaceuticals administered to
patients are accurately reported in terms of the dosage specified in
the full HCPCS code descriptor. That is, units should be reported in
multiples of the units included in the HCPCS descriptor. For example,
if the descriptor of the drug code includes 5 mg, and 5 mg of the drug
was administered to the patient, the units billed should be 1. If the
descriptor of the drug code includes 5 mg, but 25 mg of the drug was
administered to the patient, the units billed should be 5. Hospitals
should not bill the units for HCCPS codes based on the way the drug,
biological, or radiopharmaceutical is packaged, stored, or stocked.
HCPCS short descriptors are limited to 28 characters, including spaces,
so short descriptors do not always capture the complete description of
the products. Therefore, before submitting Medicare claims for drugs,
biologicals, and radiopharmaceuticals, we remind commenters that it is
extremely important for hospitals to review the complete long
descriptors for the applicable HCPCS codes in order to determine the
appropriate units to be reported.
After consideration of the public comments received, we are
finalizing our proposal, without modification, to identify diagnostic
radiopharmaceuticals as those radiopharmaceuticals with the term
``diagnostic'' in their long code descriptors and therapeutic
radiopharmaceuticals as those radiopharmaceuticals with the term
``therapeutic'' in their long code descriptors. Our final payment
policy packages payment for all diagnostic radiopharmaceuticals in CY
2008. The related public comments and our responses to the proposed
payment methodology for diagnostic radiopharmaceuticals are presented
in section II.A.4.c.(5) of this final rule with comment period.
In the case of contrast agents, while we have ASP data that can be
a proxy for average hospital acquisition cost and associated handling
and preparation costs, payment for almost all contrast agents is
packaged under the OPPS for CY 2008 based on the $60 per day packaging
threshold. Therefore, as discussed in the proposed rule, we believed
that it is most appropriate to package payment for all contrast agents
for CY 2008 to better provide for payment for the associated tests and
procedures that promotes hospital efficiency. Our final policy to
package payment for all contrast agents in CY 2008, and the related
public comments and our responses to the proposed payment methodology,
is presented in section II.A.4.c.(6) of this final rule with comment
period.
In summary, we view diagnostic radiopharmaceuticals and contrast
agents as ancillary and supportive to the diagnostic tests and
therapeutic procedures in which they are used. In light of our
authority to make different packaging determinations for groups of
items, and the improved reporting of hospital charges for
radiopharmaceutical handling in the CY 2006 claims data, we are
finalizing our proposal, without modification, to package payment for
contrast agents and diagnostic radiopharmaceuticals for CY 2008.
Additional discussion of our rationale and further response to public
comments received and the APC Panel recommendations regarding our
proposal to package payment for diagnostic radiopharmaceuticals and
contrast agents appears in sections II.A.4.c.(5) and II.A.4.c.(6),
respectively, of this final rule with comment period.
[[Page 66769]]
(c) Payment for Therapeutic Radiopharmaceuticals
For CY 2008, we proposed to continue separate payment for
therapeutic radiopharmaceuticals that have a mean per day cost of more
than $60, consistent with the packaging methodology applied to other
nonpass-through drugs and biologicals. We believed that therapeutic
radiopharmaceuticals are distinct from diagnostic radiopharmaceuticals
because the primary purpose of providing a therapeutic
radiopharmaceutical is the radiopharmaceutical treatment itself,
whereas a diagnostic radiopharmaceutical is administered in support of
the performance of a diagnostic nuclear medicine study that is the
primary service. For separately payable therapeutic
radiopharmaceuticals, we proposed to establish CY 2008 payment rates
based on their mean unit costs from our CY 2006 OPPS claims data.
In the CY 2007 OPPS/ASC final rule with comment period (71 FR
68095), we again reiterated our intent to develop a suitable
prospective payment methodology for radiopharmaceutical products paid
under the OPPS in future years, beginning in CY 2008. Since the start
of the temporary cost-based payment methodology for
radiopharmaceuticals in CY 2006, we have met with several interested
parties on this topic and have received several suggestions from these
stakeholders regarding payment methodologies that we could employ for
future use under the OPPS.
In considering payment options for therapeutic radiopharmaceuticals
for CY 2008, we examined several alternatives. First, we considered
retaining the CY 2007 methodology of providing payment for therapeutic
radiopharmaceuticals at a hospital's charges reduced to cost using the
hospital's overall CCR. While this option would provide consistency in
the payment methodology from year to year, we have noted on several
occasions, including in the CY 2007 OPPS/ASC final rule with comment
period and in various public forums such as the APC Panel meetings,
that this methodology was not intended to be the basis of providing
payment to hospitals for these products beyond CY 2007. Payment on a
claim-specific cost basis is not consistent with the payment of items
and services on a prospective basis under the OPPS and may lead to
extremely high or low payments to hospitals for radiopharmaceuticals,
even when those products would be expected to have relatively
predictable and consistent acquisition and handling costs across
individual clinical cases and hospitals. In addition, we have stated
that we believe 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 (71 FR
68095). For these reasons, we did not propose to use this methodology
to set their payment rates for CY 2008.
The second option we considered, and proposed, as a methodology for
providing payment for therapeutic radiopharmaceuticals in CY 2008, is
to establish prospective payment rates for separately payable
therapeutic radiopharmaceuticals using mean costs derived from the CY
2006 claims data, where the costs are 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 are unavailable. As we
stated in the CY 2007 OPPS/ASC proposed rule, we believe this
methodology provides us with the most consistent, accurate, and
efficient methodology for prospectively establishing payment rates for
separately payable therapeutic radiopharmaceuticals (71 FR 49587). As
discussed in the CY 2008 OPPS/ASC proposed rule, we believe that
adopting prospective payment based on historical hospital claims data
is appropriate because it serves as our most accurate available proxy
for the average hospital acquisition cost of separately payable
therapeutic radiopharmaceutical products (72 FR 42739). In addition, we
have found that our general prospective payment methodology based on
historical hospital claims data results in more consistent,
predictable, and equitable payment amounts across hospitals and likely
provides incentives to hospitals for efficiently and economically
providing these outpatient services. Therefore, we expect that the
hospital-specific payment variability found under a charges-reduced-to-
cost methodology would no longer affect these products under our CY
2008 proposal.
Although we received public comments on our CY 2007 proposed rule
indicating that CY 2005 claims data used for that update did not
incorporate associated overhead charges into the radiopharmaceutical
charge, in the CY 2007 OPPS/ASC final rule with comment period (71 FR
68095), we stated that we expected that hospitals would have adapted to
the CY 2006 HCPCS coding changes for some radiopharmaceuticals and
responded to our instructions to include their charges for
radiopharmaceutical handling in their charges for the
radiopharmaceutical products so these costs would be reflected in the
CY 2008 ratesetting process. This continues to be our expectation, and,
as discussed in the CY 2008 OPPS/ASC proposed rule, we believed that
the CY 2006 claims data that we are using to set the proposed CY 2008
OPPS payment rates reflect both the radiopharmaceutical charge and
associated overhead charges. As discussed at the March 2007 APC Panel
meeting, our CY 2006 claims data show that a greater proportion of
radiopharmaceuticals experienced an increase in their median costs from
CY 2005 to CY 2006 than experienced a decrease. We indicated that this
trend is consistent with the agency's expectations that hospitals would
comply with our instructions to include charges for radiopharmaceutical
handling in their charges for the radiopharmaceutical products for CY
2006. Therefore, we believed that setting CY 2008 prospective payment
rates based on CY 2006 hospital claims data as described above serves
as an acceptable combined proxy for average hospital acquisition costs
and radiopharmaceutical handling.
As we discussed in the CY 2008 OPPS/ASC proposed rule, during
meetings with external stakeholders over the past year, we have been
presented with several other suggestions regarding OPPS payment for
therapeutic radiopharmaceuticals in CY 2008. One of these options
included a suggestion that we employ alternative trimming methodologies
in order to produce a claims-based mean cost that would more accurately
reflect hospital purchase prices for these products. We did not propose
a methodology based on special OPPS data trimming for CY 2008 for the
following reasons. First, the OPPS has a standard data trimming
methodology to calculate drug, biological, and radiopharmaceutical per
day costs from hospital claims data. This includes both a specific trim
on units for drugs, biologicals, and radiopharmaceuticals that is
3 standard deviations from the geometric mean, and a
standard trim of any line-item with a cost per unit that is 3 standard deviations from the geometric mean that is applied
across all items and services. Both trims are conducted on the
transformed variable, taking the natural log of both units and cost per
unit, in order to trim evenly relative to the center of the
distribution. Both units
[[Page 66770]]
and costs per unit are never negative, and there are some therapeutic
radiopharmaceuticals with very high units and high costs per unit in
our hospital claims data. These trims are conservative and typically
eliminate only the most egregious observations, ones that could be due
to erroneous reporting. For therapeutic radiopharmaceuticals at the
time of the proposed rule, the unit trim alone removed all items that
would have been eliminated under the cost trim, and with the exception
of HCPCS code A9563 (Sodium phosphate P-32, therapeutic, per
millicurie), this trim removed observations with unit costs below the
mean unit cost. That is, overall, the result of applying our systematic
trimming methodology increased the mean unit cost reported in Table 44
of the proposed rule (72 FR 42740).
As a payment system based on relative payment weights, altering the
trimming methodology for a particular set of services could unduly
influence the relativity of the resulting payment weights for those
particular services and could inappropriately redistribute payments in
a budget neutral OPPS. We have no reason to believe that hospitals
report costs differently for radiopharmaceuticals than they do for
other items. As we discussed further in section II.A.1. of this final
rule with comment period, what is important for setting appropriate
payment rates for most services under a prospective payment system is
accuracy in estimating the relative costliness of services, and not the
nominal value of the observed cost. Second, we are not convinced that
employing an alternative overall trimming methodology would result in
the most appropriate cost estimates for therapeutic
radiopharmaceuticals. We have noted our belief that because hospitals
were paid in CY 2006 for each therapeutic radiopharmaceutical they
reported according to a claim-specific charge that was reduced to cost
for payment, hospitals had an incentive to accurately account for the
full costs of these products in establishing their charges. In
addition, we have no way of knowing the specific clinical scenario that
resulted in any given claim with certain reported units and charges for
a therapeutic radiopharmaceutical. Therefore, we did not believe it
would be appropriate to utilize a ratesetting methodology that could
disregard correctly coded claims. While we appreciated this
recommendation, we did not propose a payment methodology that included
additional trimming of hospital claims data for therapeutic
radiopharmaceutical products for CY 2008.
Recommendations other than trimming centered around providing CMS
with external data on radiopharmaceutical costs. One specific
recommendation that we received from interested stakeholders suggested
that we allow hospitals to submit their invoices to CMS. With the
invoice information, CMS could establish a prospective payment rate for
radiopharmaceuticals that would be calculated taking into consideration
the total amount invoiced for the radiopharmaceutical, transportation
costs, and applicable rebates. While this payment rate would not
include payment for certain radiopharmaceutical overhead and handling
costs, stakeholders suggested that costs could be packaged into the
associated procedure payment for the radiopharmaceutical. Stakeholders
also generally recommended that we could collect external data from
various sources (such as manufacturers, nuclear pharmacies, and others)
to use for therapeutic radiopharmaceuticals.
At its September 2007 meeting, the Panel recommended that CMS
create a composite for BEXXAR[supreg] or related therapies and present
it for the Panel's consideration at the next APC Panel meeting. We are
accepting this recommendation and will provide information and analyses
regarding commonly observed combinations of services provided with
radioimmunotherapy treatments to the APC Panel at its 2008 winter
meeting.
We received many public comments on our CY 2008 proposal to
establish payments for separately payable therapeutic
radiopharmaceuticals based on their mean unit costs from hospitals
claims. A summary of the public comments and our responses follow.
Comment: Many commenters asked CMS to continue the CY 2007 CCR
methodology for payments for all radiopharmaceutical products in CY
2008. The commenters cited inaccurate and incomplete data from
hospitals as a reason to continue this methodology.
Response: For the CY 2007 rulemaking cycle, we also received many
comments that we should not proceed with our CY 2007 proposal to
establish a prospective payment methodology for radiopharmaceuticals.
At that time, the commenters were concerned that hospital claims data
may be inaccurate due to hospitals slow adoption of our billing
guidance to include radiopharmaceutical pharmacy overhead charges in
the charge for the radiopharmaceutical. Because of these and other
concerns, we concluded that, for CY 2007, there was sufficient reason
to extend the temporary policy of paying for radiopharmaceuticals at
charges reduced to cost for one additional year. We noted that it was
still our intention to move toward a prospective payment methodology
for radiopharmaceuticals in the OPPS (71 FR 68095). In the CY 2008
OPPS/ASC proposed rule, we again noted our intent to move to a
prospective payment for therapeutic radiopharmaceuticals under the OPPS
and did not propose to continue providing payment for therapeutic
radiopharmaceuticals at hospital charges reduced to cost using the
hospital's overall CCR for the reasons cited previously. In particular,
payment on a claim-specific cost basis is not consistent with the
payment of items and services on a prospective basis under the OPPS and
may lead to extremely high or low payments to hospitals for
radiopharmaceuticals, even when those products would be expected to
have relatively predictable and consistent acquisition and handling
costs across individual clinical cases and hospitals.
Comment: Several commenters requested that CMS implement a policy
that would accept external data submissions from various groups,
including nuclear pharmacies, hospitals, and manufacturers. The
commenters recommended that CMS collect Estimated Average Acquisition
Cost (EAAC), Calculated Pharmacy Sales Price (CPSP), or average selling
nuclear pharmacy price (ADNPP) data through this process. In addition,
the commenters suggested that CMS could collect hospital invoice data
to establish a prospective payment rate for radiopharmaceuticals that
would be calculated, taking into consideration the total amount
invoiced for the radiopharmaceutical, transportation costs, and
applicable rebates.
Some commenters also recommended that, as CMS proposed the
reporting of pharmacy overhead charges for drugs and biologicals on
uncoded revenue code lines for CY 2008, CMS should change its
instructions for reporting radiopharmaceutical handling charges. Some
commenters suggested that the radiopharmaceutical handling charges be
reported separately on uncoded revenue code lines instead of being
included in the charge for the radiopharmaceutical under current CMS
instructions. The commenters believed this would allow the costs of
radiopharmaceutical handling to be packaged into payment for the
associated procedure, such as a radiopharmaceutical administration
procedure, in future years when CY
[[Page 66771]]
2008 claims data become available for ratesetting.
Response: We did not propose a therapeutic radiopharmaceutical
payment methodology using external data for CY 2008 for the following
reasons. First, any approach relying on external data has the
disadvantage of differentially influencing the relativity of payment
weights for radiopharmaceuticals in the budget neutral OPPS payment
system where we utilize a standard ratesetting methodology for other
services. In addition, it is not clear that invoice information from
hospitals or cost information from nuclear pharmacies or manufacturers
would be more accurate than hospitals' costs for radiopharmaceuticals
that we currently calculate based on hospitals' charges reduced to cost
by application of a CCR, and such external information would generally
exclude the costs of the hospital's handling of the
radiopharmaceuticals. However, as noted in the CY 2008 OPPS/ASC
proposed rule (72 FR 42740), we do not currently identify separate
costs for this radiopharmaceutical handling that we could then package
into the costs of the associated diagnostic nuclear medicine studies
and treatment procedures. Moreover, hospitals currently have the
flexibility to set their charges for therapeutic radiopharmaceuticals,
taking into account a variety of factors, including acquisition costs
and transportation costs. Therefore, we believed, and continue to
believe, it is likely that hospitals are already taking this
information into consideration when establishing their charges.
Further, we have already instructed hospitals to include overhead
charges for radiopharmaceuticals in the charge for the
radiopharmaceutical product. We have received several reports that
hospitals have made these changes, when necessary, and that other
changes are in process to conform to our instructions. A ratesetting
approach based on external data could be inconsistent with the charging
practices of those hospitals that have been working over the past 2
years to align their charging practices with our stated instructions.
Moreover, adoption of any methodology systematically relying on
external data also would be administratively burdensome for us because
we would need to collect, process, and review external information to
ensure that it was valid, reliable, and representative of a diverse
group of hospitals so that it could be used to establish rates for all
hospitals. For these reasons, we did not propose and are not finalizing
a policy to collect hospital invoices or otherwise rely on external
data in order to establish prospective payment rates for therapeutic
radiopharmaceuticals for CY 2008.
We are not adopting our proposal to have hospitals separately
report charges for pharmacy overhead associated with drugs and
biologicals on uncoded revenue code lines, as discussed earlier.
Therefore, we also do not believe it would be appropriate to provide
instructions to hospitals to separately report their
radiopharmaceutical handling charges in addition to the charge for the
radiopharmaceutical. Hospitals have recently become accustomed to our
CY 2006 guidance that they should consider all handling costs in
setting their charges for radiopharmaceuticals, and we see no reason
for them to change this practice. We will continue to provide payment
for the handling costs of radiopharmaceuticals through the packaged or
separate payment for the products in CY 2008, just as we will for the
pharmacy handling costs of drugs and biologicals.
Comment: Many commenters expressed concern over the proposed
payment rates for very high cost therapeutic radiopharmaceuticals. The
commenters stated that the proposed payment rates are inadequate to
cover the cost of the therapeutic radiopharmaceutical itself, let alone
the added costs of handling, shipping, and compounding. The commenters
noted that inadequate payment rates may lead to beneficiary access
issues. Some commenters suggested that systematic special trimming of
claims data should be considered in order to products costs that
reflect actual hospital purchase prices for radiopharmaceuticals. A few
commenters recommended using ASP as an alternative payment methodology
for the very costly therapeutic radiopharmaceuticals or other
methodologies based on external data. One commenter noted its intent to
submit ASP information for an expensive therapeutic radiopharmaceutical
so that CMS would have an alternative methodology with which to price
the product.
Response: While we understand the commenters' concerns regarding
the unique circumstances associated with radiopharmaceutical products,
especially very high cost therapeutic radiopharmaceuticals, for the
majority of services under the OPPS, payment is made according to
prospectively established payment rates that are related to hospitals'
costs for those services as calculated from claims data. For the past 2
years, hospitals have been paid on a CCR methodology for separately
payable therapeutic radiopharmaceuticals. Therefore, hospitals had
every incentive to submit a charge representative of their acquisition
cost and associated handling costs for these radiopharmaceuticals. To
that extent, we believe that the hospital claims data that we have
available for ratesetting purposes in CY 2008 are reliable and
accurate.
We note that, for CY 2008, separately payable therapeutic
radiopharmaceuticals meet the definition of SCODs and therefore are to
be paid at average acquisition cost. While we are implementing a policy
to provide payment for therapeutic radiopharmaceuticals through the
standard OPPS methodology relying on hospital claims data for CY 2008
as a proxy for average acquisition cost as described below, we note
that there is an established process already in place for submitting
pricing data for other SCODs to be used for payment purposes. While we
understand that the standard ASP methodology may not work for all
therapeutic radiopharmaceuticals, we received comments that this
approach would work for certain products. Therefore, to the extent that
manufacturers or stakeholders believe that the ASP methodology that we
currently use for the payment of separately payable drugs and
biologicals under the OPPS is appropriate for their particular product,
we seek comments on that approach and comments on how
radiopharmaceutical ASP information could be used in future
ratesetting.
As we discussed in the proposed rule (72 FR 42739), we do not agree
with the suggestion of some commenters that special trimming
methodologies should be applied to develop claims-based means costs for
therapeutic radiopharmaceuticals. No commenters provided specific
approaches for our consideration. We believe the standard OPPS data
trimming methodology is appropriate for establishing the payment rates
for therapeutic radiopharmaceuticals. Altering the systematic trimming
methodology for these products in particular could inappropriately
redistribute payments in the budget neutral OPPS, and we have no reason
to believe that hospitals report costs differently for
radiopharmaceuticals than they do for other items. We continue to
believe that because hospitals were paid in CY 2006 for each
therapeutic radiopharmaceutical according to a claim-specific charge
that was adjusted to cost for payment, hospitals had an
[[Page 66772]]
incentive to accurately account for the full costs of these products in
establishing their charges.
We examined the final rule claims data for the eight therapeutic
radiopharmaceuticals that we proposed for separate payment in CY 2008
after we applied the standard OPPS data trimming methodology of 3 standard deviations from the geometric mean. The standard trim
removes data outliers, which are rare observations with extremely
different units and costs from most occurrences in the distribution.
Our analysis showed that in the case of HCPCS code A9543 (Yttrium Y-90
ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40
millicuries) and A9545 (Iodine I-131 tositumomab, therapeutic, per
treatment dose), there were one and three providers, respectively, who
consistently (more than 2 times) reported charges in the CY 2006 claims
data that were less than $100 when converted to costs as part of the
usual ratesetting process. In addition, we had relatively few claims
overall for these two products from CY 2006, only 456 line-item charges
on 455 days for HCPCS code A9543 (458 units) and 262 line-item charges
on 261 days for HCPCS code A9545 (342 units). The numerous repetitive
claims with exceptionally low costs had not been removed in the
standard OPPS mean cost calculation because the significant number of
these aberrant claims increased the standard deviation and were not
rare observations. In light of the specialized nature of these
radioimmunotherapy agents, we believe that these claims were
incorrectly coded based on their extremely low costs. Therefore, these
claims from the several providers with very low costs are highly
unlikely to represent claims for treatment with the products described
by HCPCS codes A9543 and A9545. After removing these likely incorrectly
coded claims in the ratesetting process, we were left with 360 line-
item charges on 359 days for HCPCS code A9543 (354 units) and 237 line-
item charges on 326 days for HCPCS code A9545 (238 units). These very
low cost claims constituted between one quarter and one third of the
units for HCPCS codes A9543 and A9545, contributing significantly to
the calculation of the products' mean unit costs. While the mean per
unit cost was approximately $11,926 for HCPCS code A9543 based on all
claims, when the repetitive claims from one provider with very low
costs were removed, the mean per day cost was approximately $15,024.
Similarly, while the mean per unit cost was approximately $7,844 for
HCPCS code A9545 based on all claims, when the repetitive claims from
three providers with very low costs were removed, the mean per day cost
was approximately $11,264. We continue to believe that providing
prospective payment for the costs of the eight separately payable
therapeutic radiopharmaceuticals and their handling is the most
appropriate payment methodology for CY 2008, because we believe that
hospitals have set their charges for these products while taking into
account a variety of factors, including acquisition and transportation
costs. We believe this methodology provides us with the most
consistent, accurate, and efficient methodology for prospectively
establishing payment rates for separately payable therapeutic
radiopharmaceuticals. The adoption of prospective payment based on
historical hospital claims data is appropriate because it currently
serves as our most accurate available proxy for the average hospital
acquisition cost of separately payable therapeutic radiopharmaceutical
products. In addition, in the cases of HCPCS codes A9543 and A9445, we
have specifically removed the likely incorrectly coded claims from
several providers before applying our standard ratesetting methodology
to calculating their mean costs from CY 2006 claims.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, with modification to eliminate likely
incorrectly coded claims from several providers for HCPCS codes A9543
and A9545 as described above, to provide payment for separately payable
therapeutic radiopharmaceuticals based on their mean unit costs from CY
2007 claims. These therapeutic radiopharmaceuticals and their final CY
2008 payment rates are shown in Table 31 below.
Table 31.--CY 2008 Separately Payable Therapeutic Radiopharmaceuticals
----------------------------------------------------------------------------------------------------------------
Final CY Final CY 2008
HCPCS Code Short descriptor 2008 APC Final CY 2008 SI payment rate
----------------------------------------------------------------------------------------------------------------
A9517................... I131 iodide cap, rx............ 1064 K....................... $15.24
A9530................... I131 iodide sol, rx............ 1150 K....................... 11.22
A9543................... Y90 ibritumomab, rx............ 1643 K....................... 15,023.91
A9545................... I131 tositumomab, rx........... 1645 K....................... 11,264.25
A9563................... P32 Na phosphate............... 1675 K....................... 113.60
A9564................... P32 chromic phosphate.......... 1676 K....................... 119.18
A9600................... Sr89 strontium................. 0701 K....................... 612.06
A9605................... Sm 153 lexidronm............... 0702 K....................... 1,361.07
----------------------------------------------------------------------------------------------------------------
Comment: Several commenters stated that charge compression may be
adversely affecting estimates of the mean cost for expensive
radiopharmaceuticals.
Response: As discussed in more detail in section II.A.1.c. of this
final rule with comment period, while we did not propose to implement
adjustments for charge compression for CY 2008 based on the RTI report
for inpatient services, which focused only on inpatient charges, we
planned steps to explore this issue further for the future. Under
contract with RTI, we are currently examining an all-charges model that
would compare variation in CCRs with variation in charges to establish
regression-adjusted CCRs that could be applied to both inpatient and
outpatient charges. We will consider whether it would be appropriate to
adopt regression-based CCRs for the OPPS in the future after we receive
RTI's comprehensive review of the OPPS cost estimation methodology and
review the results of the use of both inpatient and outpatient charges
across all payers to reestimate regression-based CCRs.
b. Payment for Nonpass-Through Drugs, Biologicals, and
Radiopharmaceuticals with HCPCS Codes, but without OPPS Hospital Claims
Data
Pub. L. 108-173 does not address the OPPS payment in CY 2005 and
after for 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.
[[Page 66773]]
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, 2006, and 2007, 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's
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. However, for CY 2008 we proposed to
explicitly account for the pass-through payment amount associated with
pass-through drugs and biologicals, in the context of our CY 2008
proposal for the payment of separately payable nonpass-through drugs
and biologicals at ASP+5 percent.
We did not receive any public comments explicitly on the topic of
our proposed payment methodology for nonpass-though drugs, biolgicals,
and radiopharmaceuticals with HCPCS codes, but without OPPS hospital
claims data. Therefore, we are finalizing our proposal, without
modification, to provide payment for these new drugs and biologicals
with HCPCS codes as of January 1, 2008, but which do not have pass
through status and are without OPPS hospital claims data, at ASP+5
percent, consistent with our final payment methodology for other
separately payable nonpass-through drugs and biologicals. This policy
ensures that new nonpass-through drugs and biologicals are treated like
other drugs and biologicals under the OPPS, unless they are granted
pass-through status. Only pass through drugs and biologicals receive a
different payment for CY 2008, generally equivalent to the payment
these drugs and biologicals receive in the physician's office setting,
consistent with the requirements of the statute. Payment for all new
nonpass through diagnostic radiopharmaceuticals will be packaged.
In accordance with the ASP methodology, in the absence of ASP data,
we proposed, for CY 2008, to continue the policy we implemented during
CYs 2005, 2006, and 2007 of using the WAC for the product to establish
the initial payment rate for new nonpass through drugs, and biologicals
with HCPCS codes, but which are without OPPS claims data. As discussed
in the proposed rule (72 FR 42741), if the WAC is also unavailable, we
would make payment at 95 percent of the product's most recent AWP. We
received no comments on this proposal and are finalizing it without
modification.
We also proposed to assign status indicator ``K'' to HCPCS codes
for new drugs and biologicals for which we have not received a pass-
through application. Again, we received no comments and we are
finalizing this proposal without modification. We further note that
with respect to new items for which we do not have ASP data, once their
ASP data become available in later quarter submissions, their payment
rates under the OPPS will be adjusted so that the rates are based on
the ASP methodology and set to ASP+5 percent.
For CY 2008, we also proposed to base payment for new therapeutic
radiopharmaceuticals with HCPCS codes as of January 1, 2008, but which
do not have pass-through status, on the WACs for these products as ASP
data for radiopharmaceuticals are not available. As proposed, if the
WACs are also unavailable, we would make payment for the therapeutic
radiopharmaceuticals at 95 percent of their most recent AWPs. Analogous
to new drugs and biologicals, we proposed to assign status indicator
``K'' to HCPCS codes for new therapeutic radiopharmaceuticals for which
we have not received a pass-through application. We received no
comments and are finalizing this proposal without modification.
Consistent with other ASP-based payments, for CY 2008, we proposed
to make any appropriate adjustments to the payment amounts for drugs
and biologicals in this final rule with comment period and also on a
quarterly basis on our Web site during CY 2008 if later quarter ASP
submissions (or more recent WACs or AWPs) indicate that adjustments to
the payment rates for these drugs and biologicals are necessary. As
proposed, the payment rates for new therapeutic radiopharmaceuticals
would also be adjusted accordingly. We also proposed to make
appropriate adjustments to the payment rates for new drugs and
biologicals in the event that they become covered under the CAP in the
future. As noted in the proposed rule (72 FR 42741), the new CY 2008
HCPCS codes for drugs, biologicals, and therapeutic
radiopharmaceuticals were not available at the time we developed the
proposed rule. We have included these changes in Table 32 below.
Table 32.--New CY 2008 HCPCS codes for Drugs, Biologicals, and Radiopharmaceuticals
----------------------------------------------------------------------------------------------------------------
CY 2008 SI
CY 2007 HCPCS for CY 2007 CY 2008 CY 2008 CY 2008 CY 2008 long descriptor
HCPCS code HCPCS SI APC
----------------------------------------------------------------------------------------------------------------
A9565....................... D A9572 N -- Indium IN-111 pentetreotide,
diagnostic, per study dose, up to
6 millicuries.
C9232....................... D J1743 G 9232 Injection, idursulfase, 1mg.
C9233....................... D J2778 G 9233 Injection, ranibizumab, 0.1 mg.
C9234....................... D J0220 K 9234 Injection, aglucosidase alfa, 10
mg.
C9235....................... D J9303 G 9235 Injection, panitumumab, 10 mg.
C9236....................... D J1300 G 9236 Injection, eculizumab, 10 mg.
C9350....................... D C9352 G 9350 Microporous collagen implantable
tube (Neuragen Nerve Guide), per
centimeter length.
C9350....................... D C9353 G 1169 Microporous collagen implantable
slit tube (NeuraWrap Nerve
Protector), per centimeter
length.
C9351....................... D J7348 G 9351 Dermal (substitute) tissue of
nonhuman origin, with or without
other bioengineered or processed
elements, without metabolically
active elements (TissueMend) per
square centimeter.
[[Page 66774]]
C9351....................... D J7349 G 1141 Dermal (substitute) tissue of
nonhuman origin, with or without
other bioengineered or processed
elements, without metabolically
active elements (PriMatrix) per
square centimeter.
J1567....................... D J1561 K 0948 Injection, immune globulin,
(Gamunex), intravenous, non-
lyophilized (e.g. liquid), 500
mg.
J1567....................... D J1568 K 0943 Injection, immune globulin,
(Octagam), intravenous, non-
lyophilized, (e.g. liquid), 500
mg.
J1567....................... D J1569 K 0944 Injection, immune globulin,
(Gammagard Liquid), intravenous,
non-lyophilized, (e.g. liquid),
500 mg.
J1567....................... D J1572 K 0947 Injection, immune globulin,
(Flebogamma), intravenous, non-
lyophilized (e.g. liquid), 500
mg.
J7319....................... D J7321 K 0873 Hyaluronan or derivative, Hyalgan
or Supartz, for intra-articular
injection, per dose.
J7319....................... D J7322 K 0874 Hyaluronan or derivative, Synvisc,
for intra-articular injection,
per dose.
J7319....................... D J7323 K 0875 Hyaluronan or derivative,
Euflexxa, for intra-articular
injection, per dose.
J7319....................... D J7324 K 0877 Hyaluronan or derivative,
Orthovisc, for intra-articular
injection, per dose.
J7345....................... D J7348 G 9351 Dermal (substitute) tissue of
nonhuman origin, with or without
other bioengineered or processed
elements, without metabolically
active elements (Tissuemend) per
square centimeter.
J7345....................... D J7349 G 1141 Dermal (substitute) tissue of
nonhuman origin, with or without
other bioengineered or processed
elements, without metabolically
active elements (Primatrix) per
square centimeter.
Q4079....................... D J2323 G 9126 Injection, natalizumab, 1 mg.
Q4083....................... D J7321 K 0873 Hyaluronan or derivative, Hyalgan
or Supartz, for intra-articular
injection, per dose.
Q4084....................... D J7322 K 0874 Hyaluronan or derivative, Synvisc,
for intra-articular injection,
per dose.
Q4085....................... D J7323 K 0875 Hyaluronan or derivative,
Euflexxa, for intra-articular
injection, per dose.
Q4086....................... D J7324 K 0877 Hyaluronan or derivative,
Orthovisc, for intra-articular
injection, per dose.
Q4087....................... D J1568 K 0943 Injection, immune globulin,
(Octagam), intravenous, non-
lyophilized, (e.g. liquid), 500
mg.
Q4088....................... D J1569 K 0944 Injection, immune globulin,
(Gammagard Liquid), intravenous,
non-lyophilized, (e.g. liquid),
500 mg.
Q4089....................... D J2791 K 0945 Injection, rho(d) immune globulin
(human), (Rhophylac),
intravenous, 100 iu.
Q4090....................... D J1571 K 0946 Injection, hepatitis b immune
globulin (Hepagam B),
intramuscular, 0.5 ml.
Q4091....................... D J1572 K 0947 Injection, immune globulin,
(Flebogamma), intravenous, non-
lyophilized (e.g. liquid), 500
mg.
Q4092....................... D J1561 K 0948 Injection, immune globulin,
(Gamunex), intravenous, non-
lyophilized (e.g. liquid), 500
mg.
Q4095....................... D J3488 G 0951 Injection, zoledronic acid
(Reclast), 1 mg.
Q9945....................... D Q9965 N ......... Low osmolar contrast material, 100-
199 mg/ml iodine concentration,
per ml.
Q9946....................... D Q9965 N ......... Low osmolar contrast material, 100-
199 mg/ml iodine concentration,
per ml.
Q9947....................... D Q9966 N ......... Low osmolar contrast material, 200-
299 mg/ml iodine concentration,
per ml.
Q9948....................... D Q9966 N ......... Low osmolar contrast material, 200-
299 mg/ml iodine concentration,
per ml.
Q9949....................... D Q9967 N ......... Low osmolar contrast material, 300-
399 mg/ml iodine concentration,
per ml.
Q9950....................... D Q9967 N ......... Low osmolar contrast material, 300-
399 mg/ml iodine concentration,
per ml.
Q9952....................... D A9579 N ......... Injection, gadolinium-based
magnetic resonance contrast
agent, not otherwise specified
(nos), per ml.
A9501 N ......... Technetium TC-99M teboroxime,
diagnostic, per study dose.
A9509 N ......... Iodine I-123 sodium iodide,
diagnostic, per millicurie.
A9569 N ......... Technetium TC-99M exametazime
labeled autologous white blood
cells, diagnostic, per study
dose.
A9570 N ......... Indium IN-111 labeled autologous
white blood cells, diagnostic,
per study dose.
A9571 N ......... Indium IN-111 labeled autologous
platelets, diagnostic, per study
dose.
A9576 N ......... Injection, gadoteridol, (ProHance
Multipack), per ml.
A9577 N ......... Injection, gadobenate dimeglumine
(MultiHance), per ml.
A9578 N ......... Injection, gadobenate dimeglumine
(MultiHance Multipack), per ml.
C9238 K 9238 Injection, levetiracetam, 10 mg.
C9239 G 1168 Injection, temsirolimus, 1 mg.
J0400 K 1165 Injection, aripiprazole,
intramuscular, 0.25 mg.
J1573 K 1138 Injection, hepatitis b immune
globulin (Hepagam B),
intravenous, 0.5 ml.
J2724 K 1139 Injection, protein c concentrate,
intravenous, human, 10 iu.
J9226 K 1142 Histrelin implant (Supprelin LA),
50 mg.
----------------------------------------------------------------------------------------------------------------
There are several nonpass-through drugs and biologicals that were
payable in CY 2006 and/or CY 2007 for which we do not have any CY 2006
hospital claims data. These items were shown in Table 45A of the
proposed rule (72 FR 42762). In order to determine the packaging status
of these items for CY 2008, we calculated an estimate of the
[[Page 66775]]
per day cost of each of these items by multiplying the payment rate for
each product based on ASP+5 percent, similar to other nonpass-through
drugs and biologicals paid separately under the OPPS, by an estimated
average number of units of each product that would typically be
furnished to a patient during one administration in the hospital
outpatient setting. We proposed to package items for which we estimate
the per administration cost to be less than or equal to $60, which is
the general packaging threshold that we proposed for drugs,
biologicals, and radiopharmaceuticals in CY 2008. We proposed that the
CY 2008 payment for separately payable items without CY 2006 claims
data would be based on ASP+5 percent, similar to other separately
payable nonpass-through drugs and biologicals under the OPPS. In
accordance with the ASP methodology used in the physician's office
setting, in the absence of ASP data, we would use the WAC for the
product to establish the initial payment rate. However, we note that if
the WAC is also unavailable, we would make payment at 95 percent of the
most recent AWP available.
We did not receive any public comments on this proposal and,
therefore, are finalizing the proposal without modification. Table 33
lists all of the nonpass-through drugs and biologicals without
available CY 2006 claims data to which these final policies would apply
in CY 2008.
Table 33.--Drugs and Biologicals Without CY 2006 Claims Data
----------------------------------------------------------------------------------------------------------------
Estimated
ASP-based average number Final CY CY 2008
HCPCS code Short descriptor payment of units per 2008 SI APC
rate administration
----------------------------------------------------------------------------------------------------------------
J0288..................... Ampho b cholesteryl sulfate...... $11.89 35 K 0735
J0364..................... Apomorphine hydrochloride........ ......... 6 N
J1324..................... Enfuvirtide injection............ $0.40 180 K 0767
J2170..................... Mecasermin injection............. $15.62 15.6 K 0805
J2315..................... Naltrexone, depot form........... $1.87 380 K 0759
J3355..................... Urofollitropin, 75 iu............ $50.22 2 K 1741
J8650..................... Nabilone oral.................... $16.80 6 K 0808
----------------------------------------------------------------------------------------------------------------
During the March 2007 APC Panel meeting, the APC Panel reiterated
its August 2006 recommendation to allow hospitals to report all HCPCS
codes for drugs. In general, OPPS recognizes the lowest available
administrative dose of a drug if multiple HCPCS codes exist for the
drug; for the remainder of the doses, we assign a status indicator
``B'' indicating that another code exists for OPPS purposes. For
example, if drug X has 2 HCPCS codes, 1 for a 1 ml dose and a second
for a 5 ml dose, the OPPS would assign a payable status indicator to
the 1 ml dose and status indicator ``B'' to the 5 ml dose. Hospitals
would then need to bill the appropriate number of units for the 1 ml
dose in order to receive payment under the OPPS. While we were not
prepared to accept this recommendation when we developed the CY 2007
OPP/ASC final rule with comment period, we indicated in that rule that
we would continue to consider the APC Panel's recommendation for future
OPPS updates (71 FR 68083 through 68084).
After further consideration of this issue, we stated in the CY 2008
OPPS/ASC proposed rule that we are now accepting the APC Panel's
recommendation because we have concluded that recognizing all of these
HCPCS codes for payment under the OPPS should not have a significant
effect on our payment methodology for drugs (72 FR 42742). We proposed
to allow hospitals to submit claims by reporting any HCPCS code for a
Part B drug that is covered under the OPPS, regardless of the unit
determination in the HCPCS code descriptor, beginning in CY 2008.
Stakeholders have told us that this policy would reduce the
administrative burden associated with our current requirement that
hospitals report drugs using only the HCPCS codes with the lowest
increments in their code descriptors. Whenever possible, we seek to
reduce hospitals' administrative burden in submitting claims for
payment under the OPPS, and we appreciate the APC Panel's
recommendation in this area.
As these HCPCS codes were previously unrecognized in the OPPS, we
do not have claims data to determine the appropriate packaging status.
Therefore, we proposed to assign these HCPCS codes the same status
indicator as the associated recognized HCPCS code (that is, the lowest
dose), as shown in Table 45B of the proposed rule (72 FR 42743). We
believed that this approach is the most appropriate and reasonable way
to implement this proposed change without impacting payment. However,
once claims data are available for these previously unrecognized HCPCS
codes, we will determine the packaging status and resulting status
indicator for each HCPCS code according to the general code-specific
methodology for determining a code's packaging status for a given
update year. We plan to closely follow our claims data to ensure that
our annual packaging determinations for the different HCPCS codes
describing the same drug do not create inappropriate payment incentives
for hospitals to report certain HCPCS codes instead of others. In our
analysis for the proposed rule, we also estimated the packaging status
of these currently unrecognized HCPCS codes by adjusting the calculated
average number of units per day for the associated recognized HCPCS
code with claims data to account for the different dosage descriptors.
We then multiplied this adjusted average number of units per day value
by the most recent ASP data available for the unrecognized HCPCS code
(listed in Table 45B of the proposed rule). As noted in the proposed
rule (72 FR 42742), this methodology yielded the same packaging
determinations and resulting status indicators for the currently
unrecognized HCPCS codes for CY 2008 as for the recognized HCPCS code
for the same drug.
We received a number of public comments on our proposal to
recognize all HCPCS codes Part B drugs for payment under the OPPS. A
summary of the public comments and our responses follow.
Comment: Many commenters supported the proposal to allow hospitals
to submit claims by reporting any HCPCS code for a Part B drug that is
covered under the OPPS, regardless of the unit determination in the
HCPCS code descriptor, beginning in CY 2008. Some commenters supported
this proposal so long as it was not mandatory to report all HCPCS
codes. One commenter disagreed with our
[[Page 66776]]
proposal and expressed concern that this would increase hospital
burden.
Response: We appreciate the general support of our proposal to
allow hospitals to submit claims by reporting any HCPCS code for a Part
B drug that is covered under the OPPS, regardless of the unit
determination in the HCPCS code descriptor. Hospitals that may be
burdened by reporting multiple HCPCS codes need not change their
current billing practices, but hospitals that would like additional
flexibility when billing for drugs with multiple HCPCS dosages may
implement these changes beginning in CY 2008.
Table 34.--Previously Unrecognized HCPCS Codes and Status Indicators for
CY 2008
------------------------------------------------------------------------
HCPCS codes Associated
newly CY 2007 HCPCS Code Final CY
recognized in SI Long descriptor recognized 2008 SI
CY 2008 in CY 2007
------------------------------------------------------------------------
J1470......... B Injection, gamma J1460 K
globulin,
intramuscular, 2 cc.
J1480......... B Injection, gamma ........... K
globulin,
intramuscular, 3 cc.
J1490......... B Injection, gamma ........... K
globulin,
intramuscular, 4 cc.
J1500......... B Injection, gamma ........... K
globulin,
intramuscular, 5 cc.
J1510......... B Injection, gamma ........... K
globulin,
intramuscular, 6 cc.
J1520......... B Injection, gamma ........... K
globulin,
intramuscular, 7 cc.
J1530......... B Injection, gamma ........... K
globulin,
intramuscular, 8 cc.
J1540......... B Injection, gamma ........... K
globulin,
intramuscular, 9 cc.
J1550......... B Injection, gamma ........... K
globulin,
intramuscular, 10 cc.
J1560......... B Injection, gamma ........... K
globulin,
intramuscular, over
10 cc.
J8521......... B Capecitabine, oral, J8520 K
500 mg.
J9094......... B Cyclophosphamide J9093 N
lyophilized, 200 mg.
J9095......... B Cyclophosphamide ........... N
lyophilized, 500 mg.
J9096......... B Cyclophosphamide ........... N
lyophilized, 1g.
J9097......... B Cyclophosphamide ........... N
lyophilized, 2g.
J9140......... B Dacarbazine, 200 mg.. J9130 N
J9290......... B Mitomycin, 20 mg..... J9280 K
J9291......... B Mitomycin, 40 mg..... ........... K
J9062......... B Cisplatin, 50 mg..... J9060 N
J9080......... B Cyclophosphamide, 200 J9070 N
mg.
J9090......... B Cyclophosphamide, 500 ........... N
mg.
J9091......... B Cyclophosphamide, 1g. ........... N
J9092......... B Cyclophosphamide, 2 g ........... N
J9110......... B Cytarabine, 500 mg... J9100 N
J9182......... B Etoposide, 100 mg.... J9181 N
J9260......... B Methotrexate sodium, J9250 N
50 mg.
J9375......... B Vincristine sulfate, J9370 N
2 mg.
J9380......... B Vincristine sulfate, ........... N
5 mg.
------------------------------------------------------------------------
Finally, in Table 45C of the proposed rule (72 FR 42743), we
proposed to package seven drugs and biologicals that were payable in CY
2006 because we lacked CY 2006 claims data and any other data related
to the ASP methodology and, therefore, we were unable to determine the
per day cost of these products. As in previous years of the OPPS, when
we are unable to determine a drug's packaging status and payment rate
due to the unavailability of hospital claims data and payment
information at the time of the final rule, we package payment for those
drugs. We did not receive any public comments on our proposal to apply
this methodology to the seven drugs included in the proposed rule. As
stated elsewhere in this rule, it is our policy to use updated claims
data to inform our final rule. Since the time of the proposed rule, we
have received hospital claims data for HCPCS code J0200 (Injection,
alatrofloxacin mesylate, 100 mg). Therefore, as we now have payment
information for HCPCS code J0200, we have determined its final CY 2008
packaging status based on hospital claims data and we will not finalize
our proposal to package this drug for CY 2008 because of the lack of
hospital claims data and payment rate information. Hospital claims data
for HCPCS code J0200 indicate that there were a total of 100 units
billed over 1 day, with a mean cost of $0.16 per unit. Therefore, the
average per day cost estimate of HCPCS code J0200 is approximately $16.
As this cost is below the $60 packaging threshold, its status is
packaged for CY 2008, according to the standard OPPS packaging
methodology for drugs and biologicals.
Therefore, we are finalizing our proposal, with modification to
exclude HCPCS code J0200, to package payment for the drugs and
biologicals listed in Table 35 below, due to missing data critical to
calculating a per day cost.
Table 35.--Drugs and Biologicals Without Information on Per Day Cost
That Are Packaged in CY 2008
------------------------------------------------------------------------
Final CY
HCPCS code Short descriptor 2008 SI
------------------------------------------------------------------------
90393..................... Vaccina ig, im................... N
90477..................... Adenovirus vaccine, type 7....... N
90581..................... Anthrax vaccine, sc.............. N
90727..................... Plague vaccine, im............... N
J0395..................... Arbutamine HCl injection......... N
[[Page 66777]]
J1452..................... Intraocular Fomivirsen na........ N
------------------------------------------------------------------------
VI. Estimate of OPPS Transitional Pass-Through Spending 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
2008 entails estimating spending for two groups of items. The first
group of items consists of those device categories that were eligible
for pass-through payment in CY 2006 or CY 2007, or both years, and that
would continue to be eligible for pass-through payment in CY 2008. The
second group contains items that we know are newly eligible, or project
would be newly eligible, for device pass-through payment in the
remainder of CY 2007 or beginning in CY 2008.
For drugs and biologicals, section 1833(t)(6)(D)(i) of the Act
establishes the pass-through payment amount for drugs and biologicals
eligible for pass-through payment as the amount by which the amount
authorized under section 1842(o) of the Act (or, if the drug or
biological is covered under a competitive acquisition contract under
section 1847B of the Act, an amount determined by the Secretary equal
to the average price for the drug or biological for all competitive
acquisition areas and year established under such section as calculated
and adjusted by the Secretary) exceeds the portion of the otherwise
applicable fee schedule amount that the Secretary determines is
associated with the drug or biological. Because we are finalizing our
CY 2008 proposal to pay for nonpass-through separately payable drugs
and biologicals under the CY 2008 OPPS at ASP+5 percent, which
represents the otherwise applicable fee schedule amount associated with
a pass-through drug or biological, while we would pay for pass-through
drugs and biologicals at ASP+6 percent or the Part B drug CAP rate, if
applicable, our estimate of drug and biological pass-through payment
for CY 2008 is not zero. Similar to estimates for devices, the first
group of drugs and biologicals requiring a pass-through payment
estimate consists of those products that were eligible for pass-through
payment in CY 2006 or CY 2007, or both years, and that would continue
to be eligible for pass-through payment in CY 2008. The second group
contains drugs and biologicals that we know are newly eligible, or
project would be newly eligible, beginning in CY 2008. The sum of the
CY 2008 pass-through estimates for these two groups of drugs and
biologicals would equal the total CY 2008 pass-through spending
estimate for drugs and biologicals with pass-through status.
B. Estimate of CY 2008 Pass-Through Spending
As we proposed, in this final rule with comment period, we are
setting the applicable percentage limit at 2.0 percent of the total
OPPS projected payments for CY 2008, consistent with our OPPS policy
from CY 2004 through CY 2007.
As we discuss in section IV.B. of this final rule with comment
period, there are two device categories receiving pass-through payment
in CY 2007 that will continue for payment during CY 2008. In accordance
with the methodology we have used to make estimates in previous years,
in cases where we have relevant claims data for the procedures
associated with a device category, we proposed to 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/ASC final rule
with comment period (71 FR 68101), 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. We developed estimated OPPS
utilization of the procedures and costs associated with the two device
categories continuing for pass-through payment into CY 2008, based upon
examination of our historical claims data, information provided in the
pass-through device category applications, and the devices' clinical
characteristics. Based on these analyses, our final estimate of pass-
through spending attributable to the first group (that is, the two
device categories continuing in CY 2008) described above is $18.1
million for CY 2008. The two device categories continuing in CY 2008,
which are reflected in this $18.1 million estimate for CY 2008 pass-
through spending, are listed in Table 36 below.
Table 36.--CY 2008 Devices with Current Pass-Through Categories
Continuing Into CY 2008
------------------------------------------------------------------------
Current pass-through device
HCPCS code APC category
------------------------------------------------------------------------
C1821...................... 1821 Interspinous process distraction
device (implantable).
L8690...................... 1032 Auditory osseointegrated device,
includes all internal and
external components.
------------------------------------------------------------------------
[[Page 66778]]
In estimating CY 2008 pass-through spending for device categories
in the second group (that is, device categories that we know at the
time of the development of this final rule with comment period will be
newly eligible for pass-through payment in CY 2008 (of which there are
none)) and contingent projections for new categories in the second
through fourth quarters of CY 2008, we used the general methodology as
described above, while also taking into account recent OPPS experience
in approving new pass through device categories. The final estimate of
CY 2008 pass-through spending for this second group is $7.5 million.
Employing our proposed methodology that the estimate of pass through
device spending in CY 2008 incorporates CY 2008 estimates of pass
through spending for device categories continuing in CY 2008, those
first effective January 1, 2008, and those device categories projected
to be approved during subsequent quarters of CY 2007 and CY 2008, our
total pass-through estimate for device categories for CY 2008 is $25.6
million.
We did not receive any public comments on our proposed methodology
to estimate transitional pass-through spending for device categories in
CY 2008. Therefore, we are finalizing our methodology for estimating
pass-through spending for categories of devices in CY 2008 as proposed,
without modification, resulting in a total pass-through spending
estimate of $25.6 million for device categories in CY 2008.
In accordance with the methodology we proposed in the CY 2008 OPPS/
ASC proposed rule, to estimate CY 2008 pass-through spending for drugs
and biologicals in the first group, specifically those drugs and
biologicals initially eligible for pass-through status in CY 2006 or CY
2007 and proposed for continuation of pass-through payment in CY 2008,
we utilized the most recent Medicare physician's office data regarding
their utilization, information provided in the respective pass-through
applications, historical hospital claims data, pharmaceutical industry
information, and clinical information regarding the drugs or
biologicals, in order to project the CY 2008 OPPS utilization of the
products. For the known drugs and biologicals that will continue on
pass-through status in CY 2008, we then estimated the total pass
through payment amount as the difference between ASP+6 percent or the
Part B drug CAP rate, as applicable, and ASP+5 percent, aggregated
across the projected CY 2008 OPPS utilization of these products. Based
on these analyses, we estimated pass-through spending attributable to
the first group (that is, the drugs and biological continuing with
pass-through eligibility in CY 2008) described above to be about $1.2
million for CY 2008. This $1.2 million estimate of CY 2008 pass through
spending for the first group of pass-through drugs reflects the current
pass-through drugs that are continuing on pass-through status into CY
2008, which are displayed in Table 27 in section V.A.3. of this final
rule with comment period.
To estimate CY 2008 pass-through spending for drugs and biologicals
in the second group (that is, drugs and biologicals that we know at the
time of development of this final rule with comment period are newly
eligible for pass-through payment as of January 1, 2008, and
projections for new drugs and biologicals that could be initially
eligible for pass-through payment in the second through fourth quarters
of CY 2008), we used utilization estimates from applicants,
pharmaceutical industry data, and clinical information as the basis for
pass through spending estimates for these drugs and biologicals for CY
2008, while also considering the most recent OPPS experience in
approving new pass through drugs and biologicals. Based on these
analyses, we estimate pass-through spending attributable to this second
group of drugs and biologicals will be $5.4 million for CY 2008.
In the CY 2008 OPPS/ASC proposed rule, we proposed that the
estimate of pass through drug and biological spending in CY 2008
incorporate CY 2008 estimates of pass-through spending for drugs and
biologicals with pass-through status in CY 2007 that would continue for
CY 2008, those first effective January 1, 2008, and those drugs and
biologicals projected to be approved during subsequent quarters of CY
2008.
We did not receive any public comments on our proposed methodology
to estimate pass-through spending for drugs and biologicals in CY 2008.
Therefore, we are finalizing our methodology for estimating pass-
through spending for drugs and biologicals in CY 2008 as proposed,
without modification, resulting in a total pass-through spending
estimate of $6.6 million for drugs and biologicals in CY 2008.
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 are eligible for pass-through payment at the time of publication
of this final rule with comment period. In addition, we have no
information identifying new radiopharmaceuticals to which a HCPCS code
might be assigned on or after January 1, 2008, for which pass through
payment status would be sought. We also have no historical data
regarding payment for new radiopharmaceuticals with pass-through status
under the methodology that we specified for the CY 2005 OPPS or the CY
2008 methodology that we describe in section V.A.3. of this final rule
with comment period. However, we do not believe that pass through
spending for new radiopharmaceuticals in CY 2008 will be significant
enough to materially affect our estimate of total pass-through spending
in CY 2008. Therefore, we are not including radiopharmaceuticals in our
final estimate of pass through spending for CY 2008. We discuss the
methodology for determining the CY 2008 payment amount for new
radiopharmaceuticals without pass through status in section V.B.3.b. of
this final rule with comment period.
We did not receive any public comments on our proposal to estimate
that pass-through spending for radiopharmaceuticals in CY 2008 will be
zero. Therefore, we are finalizing our methodology for estimating pass-
through spending for radiopharmaceuticals in CY 2008 as proposed,
without modification, resulting in a total pass-through spending
estimate of zero for radiopharmaceuticals in CY 2008.
In accordance with the comprehensive methodology described above,
we estimate that total pass through spending for the two device
categories and the drugs and biologicals that are continuing for pass-
through payment into CY 2008 and those devices, drugs, biologicals, and
radiopharmaceuticals that first become eligible for pass-through status
during CY 2008 will approximate $32.2 million, which represents 0.09
percent of total OPPS projected payments for CY 2008.
Because we estimate that pass-through spending in CY 2008 will not
amount to 2.0 percent of total projected OPPS CY 2008 spending, we will
return 1.91 percent of the pass-through pool to adjust the conversion
factor, as we discuss in section II.C. of this final rule with comment
period.
[[Page 66779]]
Accordingly, we are finalizing our proposed methodology for
estimating CY 2008 OPPS pass-through spending for drugs, biologicals,
radiopharmaceuticals, and categories of devices. Our final total pass-
through estimate for CY 2008 is $32.2 million.
VII. OPPS Payment for Brachytherapy Sources
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.
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 were 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 (that is, brachytherapy devices) 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 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.
Section 621(b)(3) of Pub. L. 108-173 required the 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 on the appropriate payments
for such devices. 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), was published
on July 24, 2006. We summarized and discussed the report's findings and
recommendations in the CY 2007 OPPS/ASC final rule with comment period
(71 FR 68103 through 68105). The GAO report principally recommended
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 recommended that we
consider using claims data for the third source studied, high dose rate
(HDR) iridium-192.
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.
In our CY 2007 annual OPPS rulemaking, we proposed and finalized a
policy of prospective payment based on median costs for the 11
brachytherapy sources for which we had claims data. We based the
prospective rates on median costs for each source from our CY 2005
claims data (71 FR 68102 through 71 FR 68114). We also indicated that
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 (71 FR 68112). We
changed the definition of status indicator ``K'' to ensure that ``K''
appropriately described brachytherapy sources to accommodate the use of
``K'' for prospective payment for brachytherapy sources (71 FR 68110).
Subsequent to publication of the CY 2007 OPPS/ASC final rule with
comment period, section 107(a) of the MIEA-TRHCA amended section
1833(t)(16)(C) of the Act by extending the payment period for
brachytherapy sources based on a hospital's charges adjusted to cost
for one additional year. This requirement for cost-based payment ends
after December 31, 2007. Therefore, we were required to continue
payment for sources based on charges adjusted to cost through CY 2007.
We also have continued using status indicator ``H'' to denote nonpass
through brachytherapy sources paid on a cost basis as a result of
enactment of this provision rather than using status indicator ``K'' to
denote prospective payment for nonpass-through brachytherapy sources,
as finalized in the CY 2007 OPPS/ASC final rule with comment period.
Section 107(b)(1) of the MIEA-TRHCA also amended section
1833(t)(2)(H) of the Act by adding a requirement for the establishment
of separate payment groups for ``stranded and non-stranded''
brachytherapy devices beginning July 1, 2007. Section 107(b)(2) of the
MIEA-TRHCA authorized the Secretary to implement this new requirement
by ``program instruction or otherwise.'' This new requirement is in
addition to the requirement for separate payment groups based on the
number, isotope, and radioactive intensity of brachytherapy devices
that was previously established by section 1833(t)(2)(H) of the Act. We
note that commenters on the CY 2007 proposed rule asserted that
stranded sources, which they described as embedded into the stranded
suture material and separated within the strand by material of an
absorbable nature at specified intervals, had greater production costs
than non-stranded sources (71 FR 68113 through 68114).
As a result of the statutory requirement to create separate groups
for stranded and non-stranded sources as of July 1, 2007, we
established several coding changes via program transmittal, effective
July 1, 2007 (Program Transmittal No. 1259, dated June 1, 2007). As
indicated in the CY 2008 proposed rule, based upon comments to our CY
2007 proposed rule and industry
[[Page 66780]]
input, we are presently aware of three sources that are currently
available in stranded and non-stranded forms: iodine-125; palladium-
103; and cesium-131 (72 FR 42746).
Therefore, in Program Transmittal No. 1259, we created six new
HCPCS codes to differentiate the stranded and non-stranded versions of
these three sources. These six new HCPCS codes replaced the three prior
brachytherapy source HCPCS codes for iodine, palladium and cesium
(C1718, C1720, and C2633, all of which were deleted as of July 1,
2007), respectively, effective July 1, 2007. In this program
transmittal, we also provided specific billing instructions to
hospitals on how to report stranded sources. We instructed providers,
when billing for stranded sources, to bill the number of units of the
appropriate source HCPCS C-code according to the number of
brachytherapy sources in the strands and specifically not to bill as
one unit per strand. If a hospital applies both stranded and non-
stranded sources to a patient in a single treatment, the hospital
should bill the stranded and non-stranded sources separately, according
to the differentiated HCPCS codes listed in the table found in that
program transmittal and included in Table 48 of the proposed rule. We
expected that these instructions would clearly indicate how hospitals
should bill for stranded and non-stranded brachytherapy sources, and
that hospital reporting of sources according to these instructions
would promote accurate claims data for the various source codes in the
future. In Program Transmittal No. 1259, we also added the term ``non-
stranded'' to the descriptors for all sources that currently have only
non-stranded versions of a source.
In Program Transmittal No. 1259, we indicated that if we receive
information that any of the other sources now designated as non-
stranded are marketed as a stranded source, we would create a code for
the stranded source. We also established two ``Not Otherwise
Specified'' (NOS) codes for billing stranded and non-stranded sources
that are not yet known to us and for which we do not have source-
specific codes. If a hospital purchases an FDA-approved and marketed
radioactive source consisting of a radioactive isotope (consistent with
our definition of a brachytherapy source eligible for separate payment
as discussed below), for which we do not yet have a separate source
code established, it should bill such sources using the appropriate NOS
code listed in Program Transmittal No. 1259, that is, C2698
(Brachytherapy source, stranded, not otherwise specified, per source)
for stranded NOS sources, or C2699 (Brachytherapy source, non-stranded,
not otherwise specified, per source) for non-stranded NOS sources,
which are also listed in Table 37 below. For example, if a new FDA-
approved stranded source comes onto the market and there is currently
only a billing code for the non-stranded source, the hospital should
bill the stranded source under C2698 (stranded NOS source) until a
specific stranded billing code for the source is established.
In Program Transmittal No. 1259, we reiterated our longstanding
policy that hospitals and other parties are invited to submit
recommendations to us for new HCPCS codes to describe new sources
consisting of a radioactive isotope, including a detailed rationale to
support recommended new sources. We will continue our endeavor to add
new brachytherapy source codes and descriptors to our systems for
payment on a quarterly basis. Such recommendations should be directed
to the Division of Outpatient Care, Mail Stop C4-05-17, Centers for
Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, MD
21244.
Finally, we noted that in the CY 2007 OPPS/ASC final rule with
comment period, we established a definition for brachytherapy source
for which separate payment under section 1833(t)(2)(H) of the Act is
required (71 FR 68113). 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 believed 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, we indicated that
the statutory language is likewise clear that devices of brachytherapy
paid separately must reflect the number, isotope, and radioactive
intensity of such devices furnished. Accordingly, we further believed
that section 1833(t)(2)(H) of the Act applies only to radioactive
devices of brachytherapy. In the CY 2007 OPPS/ASC final rule with
comment period, we also stated that we would 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 (71 FR 68113).
B. Payment for Brachytherapy Sources
As indicated above, the provision to pay for brachytherapy sources
at charges adjusted to cost expires after December 31, 2007, in
accordance with section 1833(t)(16)(C) of the Act, as amended by
section 107(a) of the MIEA-TRHCA. However, under section 1833(t)(2)(H)
of the Act, we are 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 addition,
section 1833(t)(2)(H) of the Act, as amended by section 107(b)(1) of
the MIEA-TRHCA, requires separate payment groups based on stranded and
non-stranded brachytherapy devices on or after July 1, 2007.
In the CY 2008 proposed rule, we proposed to pay separately for
each of the sources listed in Table 48 of that rule on a prospective
basis for CY 2008, with payment rates to be determined using the CY
2006 claims-based median cost per source for each brachytherapy device.
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 provision of section 1833(t)(5) of the Act. As indicated in
section II.A.2. of the proposed rule, for CY 2008 we proposed specific
prospective payment rates for brachytherapy sources, which would be
subject to scaling for budget neutrality.
We stated that we believe that adopting prospective payment for
brachytherapy sources would be appropriate for a number of reasons. The
general OPPS payment methodology is a prospective payment system using
median costs based on claims data. This prospective payment methodology
results in more consistent, predictable, and equitable payment amounts
per source across hospitals, and it prevents some of the extremely high
and low payment amounts found under a charges adjusted to cost
methodology. The proposed prospective payment would also provide
hospitals with incentives for efficiency in the provision of
brachytherapy services to Medicare beneficiaries. Moreover, the
proposed approach is consistent with our payment methodology for the
vast majority of items and services paid under the OPPS. Indeed,
section 1833(t)(2)(C) of the Act requires us to establish prospective
payment rates for the OPPS system based on median costs (or mean costs
if elected by the Secretary). As of CY 2007, only pass-through devices,
radiopharmaceuticals,
[[Page 66781]]
and brachytherapy sources were paid at charges adjusted to cost. Based
on the proposals in the CY 2008 proposed rule, only pass-through
devices would continue to be paid at charges adjusted to cost for CY
2008. As noted earlier, section 107(a) of the MIEA-TRHCA specifically
extended the payment period for brachytherapy sources based on a
hospital's charges adjusted to cost for only one additional year, CY
2007.
As explained in the proposed rule, the proposal to adopt
prospective payment for brachytherapy sources provides opportunities
for hospitals to receive additional payments under certain
circumstances through the outlier provisions and the 7.1 percent rural
SCH adjustment (72 FR 42748). 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 provision of section
1833(t)(5) of the Act. Therefore, sources could receive outlier
payments if the costs of furnishing brachytherapy sources exceed the
outlier threshold. Also, as discussed in section II.F. of the proposed
rule, as a result of our CY 2008 proposal to pay prospectively for
brachytherapy sources, we also proposed to include brachytherapy
sources in the group of services eligible for the 7.1 percent payment
increase for rural SCHs, including EACHs.
We proposed a payment methodology for separately paid brachytherapy
sources for CY 2008 based upon their median unit costs calculated using
CY 2006 claims data. Because we are required to create separate APC
groups for stranded and non-stranded sources and because our CY 2006
billing codes do not differentiate stranded and non-stranded sources,
we proposed to make certain assumptions when we estimate the median
costs for stranded and non-stranded (low activity) iodine-125,
palladium-103, and cesium-131 sources based on our CY 2006 aggregate
claims data. As stated earlier, commenters to our CY 2007 proposed rule
explained that the costs of stranded iodine, palladium and cesium
sources are higher than non-stranded versions of these sources but
provided no data regarding the relative cost relationships. Given the
reported cost differences between stranded and non-stranded sources and
the statutory requirement that we establish separate payment groups for
stranded and non-stranded sources, we believed it would be appropriate
to establish different stranded and non stranded payment rates for
iodine-125, palladium-103, and cesium-131 sources. However, in order to
establish separate stranded and non-stranded payment rates for these
three sources, we proposed to make the following assumptions in our
calculation of their median costs. Assuming that the reportedly lower
cost non-stranded sources would be unlikely to be in the top 20 percent
of the cost distribution in our aggregate (stranded and non-stranded)
CY 2006 claims data, we proposed to calculate the median cost for these
3 non-stranded sources based on the bottom 80 percent of the cost
distribution in our aggregate claims data for each source. Likewise,
assuming that the reportedly higher cost stranded sources would be
unlikely to be in the bottom 20 percent of the cost distribution in our
aggregate CY 2006 claims data, we proposed to calculate the median cost
for these 3 stranded sources based on the top 80 percent of the cost
distribution for our aggregate data. This approach to calculating
median costs for stranded and non-stranded iodine-125, palladium-103,
and cesium-131 sources resulted in proposed Medicare payment rates
based on the 60th percentile of our aggregate data for stranded sources
and the 40th percentile of our aggregate data for non-stranded sources,
which, after examining the range of our cost data for these sources,
appeared to provide a reasonable cost differential between stranded and
non-stranded sources until such time when we have claims data reported
separately for stranded and non-stranded sources.
We proposed this approach for stranded and non-stranded iodine-125,
palladium-103, and cesium-131 sources as a transitional measure, until
we have sufficient claims data for separately coded stranded and non-
stranded sources upon which to calculate the median costs for these
sources specifically. (The first partial year claims data for
separately coded stranded and non-stranded sources will be available in
CY 2007 claims data for ratesetting in CY 2009.) This methodology has
the benefits of a prospective payment methodology as discussed above
and complies with the requirements of the MIEA-TRHCA to provide
separate payment for stranded and non-stranded sources.
Table 48 of the proposed rule (72 FR 42750) included a complete
listing of the HCPCS codes, long descriptors, and APC assignments that
we currently use for brachytherapy sources paid under the OPPS as of
July 1, 2007, and the status indicators, estimated median costs, and
payment rates that we proposed for CY 2008. We noted that some of the
HCPCS codes for which we proposed payment rates for CY 2008 were not
shown in Addendum B of the proposed rule because that addendum was
based on HCPCS codes effective as of April 2007. As explained earlier,
there are some brachytherapy source HCPCS codes that were added as of
July 1, 2007. While these HCPCS codes were not shown in Addendum B, the
proposed payment rates for all brachytherapy sources were shown in
Table 48 of the proposed rule.
We invited public comment on all aspects of our proposed
brachytherapy source payment for CY 2008. We particularly encouraged
public comment on our proposed median costs estimates for stranded and
non-stranded iodine-125, palladium-103, and cesium-131 sources,
including the submission of any available information or data on cost
differences between stranded and non stranded sources. We also
indicated in the proposed rule that we were interested in receiving
information regarding the historical and current relative market share
for stranded versus non-stranded sources, particularly as used in the
care of Medicare beneficiaries and with respect to brachytherapy
treatments for different clinical conditions (72 FR 42749).
Comment: A number of commenters recommended that CMS continue
payment for brachytherapy sources using the charges adjusted to cost
methodology for CYs 2008 and 2009. Some commenters claimed that
establishing a single prospective payment rate per source would not
account for the variable costs associated with the different sources
used in brachytherapy. A commenter claimed that, based upon historical
hospital claims data, it does not appear that hospitals are charging
enough to recover their acquisition costs for expensive products in
particular. Some commenters stated that some products have low volumes
of claims from small numbers of hospitals, based on recent claims
analyses. They explained their belief that the low volume of claims for
certain sources and the wide variation in submitted charges for most
sources demonstrate that equitable payment rates that approximate true
acquisition costs for brachytherapy sources cannot be established using
Medicare claims. Several commenters asserted that CMS' brachytherapy
source claims data have unresolved problems, such as: (a) The cost of
renewable high dose rate (HDR) iridium, which may be used to treat a
number of people, is difficult to estimate, because the cost per source
depends on the number of patients treated; (b) a lack of meaningful
data to establish payment rates for stranded brachytherapy sources; (c)
large variations in per unit costs across
[[Page 66782]]
sources; (d) a lack of sufficient claims to establish rates in the
cases of 6 sources: ytterbium-169 (C2637), linear palladium (C2636),
iodine-125 solution (C2632 correctly--coded in CY 2007 as A9527), gold-
198 (C1716), cesium-131 (C2633), and non-HDR iridium (C1719); (e) two-
thirds of the current sources have proposed payment rates based on
claims from a small number (for example, fewer than 50 or 66)
hospitals; and (f) a rank order anomaly exists between the proposed
median costs of iodine-125 ($37.71) and high activity I-125 ($29.56),
with the high activity source appearing to cost less than the low
activity source, when high activity sources are reportedly more
expensive. The commenters also explained that while claims data may be
improving over time, the majority of hospitals still do not include a
brachytherapy source code on brachytherapy treatment claims, even
though a source is required, claiming that only about 31 percent of the
claims for APC 0312 (Radioelement Applications), 73 percent of the
claims for APC 0313 (Brachytherapy), and 36 percent of the claims for
APC 0651 (Complex Interstitial Source Application) include a
brachytherapy source code.
Some commenters supported the proposal to establish prospective
payment rates for brachytherapy in CY 2008 using costs derived from CY
2006 claims data, rather than through cost-based reimbursement. A
commenter supported the development of prospective payment rates for
brachytherapy sources based on CMS' claims data but was concerned that
the 2-year time lag between the hospital claims data used to establish
the proposed payment rates for brachytherapy sources and the payment
year of the proposed update would lead to CY 2008 payments that would
not reflect the actual CY 2008 costs of brachytherapy sources. The
commenters recommended the use of historical claims data, in addition
to an annual inflation rate, to determine the prospective payment
rates.
Regarding specific brachytherapy sources, a commenter claimed that
the proposed payment rate of $11,944 per source for yttrium-90 is below
the acquisition cost and provides no compensation to providers for
storage, handling and disposal costs. Two commenters indicated that
setting a fixed payment rate for High Dose Rate (HDR) iridium-192 is
problematic, because the source can be used to treat multiple patients
during its 90-day period of decay. They pointed out that the cost per
use of the source, therefore, depends on the number of patients treated
by a hospital during this period. Thus, they concluded there would be
great variability in the cost of HDR iridium treatment so CMS should
continue to pay for this source based on the charges adjusted to cost
payment methodology.
Response: We believe that median costs based on our hospital claims
data for brachytherapy sources have produced reasonably consistent per
source cost estimates over the past several years, comparable to the
patterns we have observed for many other OPPS services whose payments
are set based upon relative payment weights from claims data.
Concerning the claim that a single prospective payment per source would
not account for the variable costs across sources used, we believe that
our per source payment methodology specific to each source's
radioisotope, radioactive intensity, and stranded or non-stranded
configuration, supplemented by payment based on the number of sources
used in a specific clinical case, adequately accounts for the major
expected sources of variability across treatments.
As a prospective payment system, the OPPS relies on the concept of
averaging, where the payment may be more or less than the estimated
costs of providing a service for a particular patient, but with the
exception of outlier cases, it is adequate to ensure access to
appropriate care. In the case of brachytherapy sources for which the
law requires separate payment groups, without packaging, the costs of
these individual items could be expected to show greater variation than
some other APCs under the OPPS because higher variability in costs for
some component items and services is not balanced with lower
variability for others and because relative weights are typically
estimated using a smaller set of claims. Nevertheless, we believe that
prospective payment for brachytherapy sources based on median costs
from claims calculated according to the standard OPPS methodology is
appropriate at this point in time and would provide hospitals with the
greatest incentives for efficiency in providing brachytherapy
treatment. Under the budget neutral OPPS, it is the relativity of costs
of services, not their absolute costs, that is important, and we
believe that brachytherapy sources can now be appropriately paid
according to the standard OPPS payment approach. All services are
similarly subjected to the same 2-year lag in costs from claims data
available for ratesetting, so we believe the relative costs of OPPS
services should generally be appropriate. It is important that the same
measure of central tendency (median cost) from claims be used to
establish the payment weights for all OPPS services in order to provide
appropriate payment for all of these services. The inflation rate of
medical services is taken into consideration through the conversion
factor, which is updated annually to account for inflation and used to
calculate payment rates from the relative payment weights based on
median costs.
When the statutory requirement for payment of brachytherapy sources
at charges adjusted to cost ends on December 31, 2007, prospective
payment for brachytherapy sources based on their median costs would
make the source payment an integral part of the OPPS, rather than a
separate cost-based payment methodology within the OPPS. We believe
that consistent and predictable prospectively established payment rates
under the OPPS for brachytherapy sources are appropriate because we do
not believe 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 source utilized which would be accounted for in the standard
OPPS payment methodology as proposed. We particularly note that, under
the final CY 2008 payment policies for all OPPS services, only a few
pass-through devices that we have determined result in significant
clinical improvement would continue to be paid based on charges
adjusted to cost, as required under section 1833(t)(6)(D)(ii) of the
Act for these items.
Sources of brachytherapy have been separately paid for virtually
all of the 7 year history of the OPPS, and hospitals have now had 7
years of experience in reporting the sources separately to receive
payment for these relatively costly items. Therefore, hospitals
historically have had a strong incentive to bill for sources at charges
that reflected the costs of the sources, leading to CY 2006 data that
are sufficient to provide the basis for prospective payment. Evolution
of brachytherapy source technology, just like advances in the provision
of other OPPS services, would be reflected in updated cost data for
those sources over time, and those updated costs would be considered
each year in the annual update cycle for the OPPS. We do not believe
that special accommodation to support brachytherapy source innovation
is necessary. We believe that hospitals and physicians regularly
balance the additional benefits to
[[Page 66783]]
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.
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. For most such OPPS services, our
practice is to establish prospective payment rates based on the median
hospital costs as calculated form claims data, to provide incentives
for efficient and cost-effective delivery of these services. Under a
prospective payment system 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 prospective
payment system could pay more or less than the cost of delivering a
specific service in an individual case. We have no reason to believe
that a CY 2008 payment based on the median unit cost for HDR iridium
would place continued access to this source at risk. Furthermore, as
discussed earlier in this section and in section II.F. of this final
rule with comment period, prospective payment for brachytherapy sources
means that there would be opportunities for hospitals to receive
additional payments under the outlier provisions and the rural
adjustment.
We disagree that we are not able to set equitable rates per source
because of low volumes for some sources and variability of source costs
in our claims data. The prospective rates we proposed and are
finalizing would be applied equitably to all sources of the same type
(for example, all non-stranded iodine-125 sources, all stranded iodine-
125 sources, and so on). The nature of basing payment 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. If the use of currently low volume sources increases in
succeeding years or expands to other hospitals, these additional claims
would be represented in our claims data in future years, leading to
more robust claims data for each such source.
Comment: One commenter claimed that CMS' claims data for the
cesium-131 source show significant variation in per unit costs reported
on claims across hospitals. In addition, the commenter believed that
the number of claims and the number of hospitals submitting data for
cesium-131 sources are too low to be the basis of appropriate payment
rates for CY 2008. The commenter also indicated that it has submitted a
request for a new code for high activity cesium-131 to be effective for
separate payment as of January 1, 2008.
Response: We disagree that the number of cesium claims is too low
and the variability is too high to proceed with prospective payment for
cesium sources. Our CY 2006 claims data used for the proposed rule
included 7,435 sources and our final rule claims data include 8,652
cesium sources. The modest variability of costs observed on claims for
cesium-131 is similar to the variability we observe for other items and
services under the OPPS. We expect that some of the cost differences
associated with claims for the single HCPCS code for cesium-131 sources
reported in CY 2006 may be associated with the use of stranded versus
non-stranded sources, and we have accounted for that potential
variation through our proposal to utilize the 40th and 60th percentiles
of aggregate cost data for the single source code for ratesetting for
non-stranded and stranded sources, respectively.
We note that we have received a request for a new code for separate
payment of high activity cesium-131 sources and are currently
evaluating that request.
Comment: A number of comments expressed varying opinions concerning
the proposed payment methodology for stranded versus non-stranded
sources for iodine-125, palladium-103, and cesium-131 sources. Some
commenters explained that the CY 2006 claims data do not distinguish
between stranded and non-stranded devices, and that no meaningful data
exist to support CMS' assumptions underpinning the payment proposal for
stranded and non-stranded sources. They asserted that CMS' reasoning
that these assumptions appear to provide a reasonable cost differential
between stranded and non-stranded sources is not supported by data and
is merely guesswork. Therefore, these commenters recommended that CMS
not establish prospective payment rates for stranded and non-stranded
configurations, especially when appropriate specific codes are now in
place to collect data on these sources. The commenters also doubted
that the assumptions CMS made should apply equally to the three
isotopes with stranded and non-stranded configurations (iodine,
palladium, and cesium). Those commenters recommended that CMS continue
to pay for stranded and non-stranded sources based on charges adjusted
to cost until accurate data are collected and available for
ratesetting.
Several commenters specifically urged CMS not to modify the
proposed payment rates based on ``anecdotal comments that the Agency
may receive'' regarding stranded versus non-stranded sources. They
believed that CMS should wait until a ``comprehensive database'' of
accurate data is available. Many of these commenters generally
recommended that not only should CMS pay for stranded and non-stranded
brachytherapy sources based on charges adjusted to cost until robust
data on the different costs of these sources are available, but that
CMS should provide payment for all brachytherapy sources using the same
cost-based methodology in CY 2008.
One commenter claimed that CMS does not have meaningful data for
stranded and high activity cesium-131 to establish prospective payment
levels. The commenter also stated that the stranded versus non-stranded
cost estimate for cesium does not reflect the fact that this cost
differential can vary significantly based on the radioactive half-life
of the source, which is significant for cesium-131. In addition, the
commenter explained that cesium decays at the rate of 7 percent per day
and thus the cost differential between its loose seed and stranded seed
configurations would not be consistent with the cost differential for
stranded and non-stranded iodine and palladium sources, which also have
different decay rates. The commenter believed that using the same cost
assumptions for all sources would have a significant negative impact on
the payment for brachytherapy sources and argued that the impact on
cesium sources would be disproportionate in comparison to other
sources, due to the radioactive isotope half-life alone.
This commenter offered information as to the actual cost
differential between stranded and non-stranded sources, a specific
request that was made of the public in the proposed rule. This
[[Page 66784]]
commenter stated that the cost of non-stranded cesium sources was $61
to $75 per source, and of stranded cesium sources, $82 to $94 per
source, in comparison with proposed payment rates of approximately $51
and $97, respectively. Therefore, the commenter concluded that the
proposed payment rates would provide a disincentive to utilize non-
stranded cesium relative to stranded cesium sources, encouraging a
shift of usage to stranded cesium sources. The commenter believed that
CMS should not rush to establish prospective payment rates for stranded
and non stranded cesium sources, especially when newly established
specific source codes are now available.
Response: We agree with the commenters that our CY 2006 claims data
do not differentiate between stranded and non-stranded sources, as we
explained in the proposed rule. We proposed to apply certain
assumptions that would allow us to make prospective payment for these
sources while our newly established codes (as of July 1, 2007) would
allow us to collect specific stranded and non-stranded cost data. In
the CY 2008 OPPS/ASC proposed rule, we reiterated our intent that the
proposed payment methodology for stranded and non-stranded sources
would be a temporary payment methodology, and that we would use the
newly established codes to collect differential cost data for stranded
and non-stranded sources for future use.
While some commenters urged us not to modify the proposed payment
levels based on ``anecdotal comments that the Agency may receive,''
many of those same commenters provided only anecdotal claims that the
proposed payment levels are inappropriate and not based on meaningful
data. Additionally, such commenters did not specifically define what
they would consider to be a comprehensive database. Of note, for many
of the brachytherapy sources without stranded configurations, we have a
significant volume of claims that have demonstrated consistent hospital
costs over the last several years, and our claims data for these
sources is directly applicable to the currently reported HCPCS codes.
We thank the commenter for reporting invoice cost data on stranded
versus non-stranded cesium sources. We have received no information on
the cost differential between stranded versus non-stranded sources in
previous comments or correspondence. We note that the median cost based
on the 40th percentile for non-stranded cesium sources for this final
rule with comment period is $63, increased from the proposed $51 based
on proposed rule data, while the final rule 60th percentile for
stranded cesium sources is $97, consistent with both the proposed and
final rule data. Therefore, for the only case in which we received
information from the public regarding the costs of stranded and non-
stranded sources, the final rule 40th and 60th percentiles of aggregate
source data are aligned with the cost information provided by the
commenter for the two source configurations. While this limited
comparison with external data does not allow us to draw definitive
conclusions, it provides validation of our proposal to base the payment
for stranded versus non-stranded cesium sources on the 60th versus 40th
cost percentile from the source's aggregate CY 2006 claims data.
Comment: Other commenters were generally supportive of prospective
payment of stranded and non-stranded iodine, palladium, and cesium
sources, as well as other brachytherapy sources. Some of these
commenters believed, however, that the payment differential for
stranded versus non-stranded sources that resulted from our methodology
to use the 60th percentile cost for stranded and the 40th percentile
cost for non-stranded sources was too great. The likely result, one
commenter explained, was to encourage the use of stranded sources for
financial rather than clinical reasons. One commenter pointed out that
while the payment differential might not appear to be significant on a
per source basis, when the number of sources per procedure is
considered (for example, 50-100 sources), the cost difference to
providers would be significant. Another commenter asserted that all
seed-type sources are essentially the same and that any price
differential between stranded and non-stranded sources is a result of a
successful marketing strategy by stranded source manufacturers,
creating a price differential between stranded and non stranded sources
as a result of customer loyalty to specific products with certain
features that were initially provided at no additional cost.
Response: 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 those extremes to eliminate those claims of
exceptionally high or low cost from contributing to APC median cost
development. The statute requires us to pay for stranded and non-
stranded sources through different payment groups. As stated earlier,
our proposal to pay at the 40th and 60th cost percentiles of aggregate
data for the predecessor HCPCS codes for the three products with two
clinical configurations is a temporary payment methodology that would
provide appropriate prospective payment for these sources until more
specific claims data are available. We note that partial year data will
be available for CY 2009 ratesetting purposes. Information on the costs
of stranded and non-stranded configurations of one source is consistent
with our proposed costs for the two configurations. Therefore, we
believe that our proposed assumptions about the distribution of non-
stranded and stranded source costs in the CY 2006 aggregate data are
reasonable and consistent with the standard OPPS ratesetting
methodology, until more specific data become available. We do not
believe, based on our claims data and review of public comments, that
delaying implementation of prospective payment for any brachytherapy
sources while we are waiting for more detailed cost information is
reasonable. Coding changes occur on a regular basis, and we routinely
account for them by crosswalking historical claims data from
predecessor HCPCS codes to the newly available codes for purposes of
payment.
After consideration of the public comments received, we are
finalizing our proposal, without modification, to pay brachytherapy
sources prospectively for CY 2008, based on median costs from our CY
2006 claims data. For stranded sources, that median cost is set at the
60th percentile of the aggregate claims data for the predecessor code
for this source, and for non-stranded sources, that median cost is set
at the 40th percentile of the aggregate claims data for the predecessor
code for this source. The final brachytherapy source HCPCS codes, APC
assignments, status indicators, and median costs are displayed in Table
37 below.
[[Page 66785]]
Table 37.--Separately Payable Brachytherapy Sources
------------------------------------------------------------------------
CY 2008
HCPCS code Long descriptor APC CY 2008 status
median cost indicator
------------------------------------------------------------------------
A9527......... Iodine I-125, sodium 2632 $27 K
iodide solution,
therapeutic, per
millicurie.
C1716......... Brachytherapy source, 1716 33 K
non-stranded, Gold-
198, per source.
C1717......... Brachytherapy source, 1717 173 K
non-stranded, High
Dose Rate Iridium-
192, per source.
C1719......... Brachytherapy source, 1719 64 K
non-stranded, Non-
High Dose Rate
Iridium-192, per
source.
C2616......... Brachytherapy source, 2616 11,621 K
non-stranded,
Yttrium-90, per
source.
C2634......... Brachytherapy source, 2634 31 K
non-stranded, High
Activity, Iodine-
125, greater than
1.01 mCi (NIST), per
source.
C2635......... Brachytherapy source, 2635 46 K
non-stranded, High
Activity, Palladium-
103, greater than
2.2 mCi (NIST), per
source.
C2636......... Brachytherapy linear 2636 42 K
source, non-
stranded, Palladium-
103, per 1MM.
C2637......... Brachytherapy source, 2637 N/A B
non-stranded,
Ytterbium-169, per
source.
C2638......... Brachytherapy source, 2638 *45 K
stranded, Iodine-
125, per source.
C2639......... Brachytherapy source, 2639 **32 K
non-stranded,Iodine-
125, per source.
C2640......... Brachytherapy source, 2640 *65 K
stranded,Palladium-
103, per source.
C2641......... Brachytherapy source, 2641 **51 K
non-
stranded,Palladium-
103, per source.
C2642......... Brachytherapy source, 2642 *97 K
stranded,Cesium-131,
per source.
C2643......... Brachytherapy source, 2643 **63 K
non-stranded,Cesium-
131, per source.
C2698......... Brachytherapy source, 2698 45 K
stranded, not
otherwise specified,
per source.
C2699......... Brachytherapy source, 2699 31 K
non-stranded, not
otherwise specified,
per source.
------------------------------------------------------------------------
\*\ Estimated median cost for stranded version is based on the 60th
percentile of the aggregate (stranded and non-stranded) claims data
for this source.
\**\ Estimated median cost for non-stranded version is based on the 40th
percentile of the aggregate (stranded and non-stranded) claims data
for this source.
Furthermore, we proposed to pay the two NOS codes, C2698 and C2699,
based on a rate equal to the lowest stranded or non-stranded
prospective payment rate for such sources, respectively, on a per
source basis (as opposed, for example, to per mci). This proposed
payment methodology for NOS sources would provide payment to a hospital
for new sources, while encouraging interested parties to quickly bring
new sources to our attention so specific coding and payment could be
established. As explained earlier, we may establish new brachytherapy
source codes on a quarterly basis.
Comment: Some commenters recommended that CMS pay for all
brachytherapy sources at charges adjusted to cost, including new
sources. One commenter commended CMS for establishing two NOS codes for
billing stranded and non-stranded sources, C2698 and C2699, until
specific coding for new sources can be established.
Response: As discussed earlier in this final rule with comment
period, we are finalizing our proposal to pay for specific
brachytherapy sources prospectively based on median costs from claims.
We also believe it is most appropriate to pay for new brachytherapy
sources based on specific codes that reflect the number, radioisotope,
radioactive intensity, and stranded or non-stranded configurations of
those sources. Furthermore, we may establish new source codes on a
quarterly basis to permit separate reporting of new sources. No
commenters recommended an alternative prospective payment methodology
for NOS source codes. It is most consistent with our payment policy for
other NOS services under the OPPS to pay for NOS brachytherapy source
codes at the same payment rate as the lowest level clinically related
APC. In the case of these NOS sources that would be paid through their
own APCs, we continue to believe it is most appropriate to pay for them
at the lowest stranded or non-stranded brachytherapy source payment
rate, as applicable to each NOS code. This payment policy should
encourage prompt requests for more specific Level II HCPCS codes for
new brachytherapy sources to ensure more accurate payment for those new
sources.
After consideration of the public comments received, we are
finalizing our proposal, without modification, to pay for the two NOS
codes, C2698 and C2699, based on a rate equal to the lowest stranded or
non-stranded prospective payment rate for such sources, respectively,
on a per source basis. For CY 2008, C2698 for unspecified stranded
sources will be paid at the same rate as C2638 (Brachytherapy source,
stranded, Iodine-125, per source) and C2699 will be paid at the same
rate as C2634 (Brachytherapy source, non-stranded, High Activity,
Iodine-125, greater than 1.01 mci (NIST), per source).
Because brachytherapy sources will no longer be paid on the basis
of their charges adjusted to cost after December 31, 2007, we proposed
to discontinue our use of payment status indicator ``H'' for APCs
assigned to brachytherapy sources. For CY 2008, we proposed to use
status indicator ``K'' for all brachytherapy source APCs. As described
earlier, the definition of status indicator ``K'' was changed for CY
2007 to accommodate prospective payment for brachytherapy sources.
We received no comments specific to the proposal to change the
status indicator for brachytherapy source APCs. Therefore, we are
finalizing our proposal, without modification, to use status indicator
``K'' for all brachytherapy source APCs for CY 2008.
For CY 2008, we also proposed to implement the policy we
established in the CY 2007 OPPS/ASC final rule with comment period
(which was superseded by section 107 of the MIEA-TRHCA) regarding
payment for new brachytherapy sources for which we have no claims data.
As discussed earlier, we proposed to 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. Because we proposed to pay prospectively for brachytherapy
sources beginning in CY 2008, we proposed to implement this policy
beginning in CY 2008.
[[Page 66786]]
In the CY 2008 proposed rule (72 FR 42749), we pointed out that
there is currently one brachytherapy source, ytterbium-169 (HCPCS code
C2637, Brachytherapy source, ytterbium-169, per source), which has its
own HCPCS code, but for which we believed we lacked claims data on its
costs. In the CY 2007 OPPS/ASC proposed rule (71 FR 49598 through
49599), we explained that it was our understanding that ytterbium-169
had not yet been marketed, and furthermore that we had no CY 2005
claims data, external data, or other information on its pricing on
which to base its payment rate for CY 2007. In response to the CY 2007
proposed rule, we received no cost data or other information that we
could use to establish an informed prospective payment rate for
ytterbium-169. Therefore, in the CY 2007 OPPS/ASC final rule with
comment period (71 FR 68112), we finalized a policy of assigning HCPCS
code C2637 the nonpayable status indicator ``B'' and indicated that if
we later received relevant information, we could establish a payable
status indicator and appropriate payment rate for the ytterbium source
in a future OPPS quarterly update. This policy was superseded by
section 107(a) of the MIEA-TRHCA, which required payment for
brachytherapy sources in CY 2007 based on charges adjusted to cost. For
the CY 2008 proposed rule, we believed that we continued to lack claims
data or other information on the costs of ytteribium-169 on which to
base an informed prospective payment rate. We noted that our CY 2006
claims data showed three claims for HCPCS code C2637. We believed these
three CY 2006 claims may have been incorrectly coded claims that did
not represent claims for ytterbium, as its manufacturer commented on
the CY 2007 OPPS proposed rule that ytterbium-169 would first become
available for market in CY 2007. Consequently, for CY 2008 we again
proposed to not recognize HCPCS code C2637 and to assign it status
indicator ``B'' under the OPPS. However, as indicated in the proposed
rule, if in public comments to the proposed rule or later in CYs 2007
or 2008, we would receive relevant and reliable information on the
hospital cost for ytterbium-169 and information that this source is
being marketed, we could establish a prospective payment rate for the
source in the CY 2008 final rule with comment period or in a quarterly
OPPS update, respectively (72 FR 42749).
Comment: A few commenters recommended that CMS continue to pay for
new brachytherapy sources (as well as established sources when there
are no reliable claims-based cost data) at charges adjusted to cost,
rather than adopting the proposed methodology of using external data
and other relevant cost data on the expected cost to hospitals.
Response: As with other brachytherapy sources and other services
under the OPPS, the development of cost data for new services through
our claims data is an ongoing process. We regularly price new services,
placing them in what we consider to be appropriate New Technology or
clinical APCs. We make ongoing adjustments to their assignments as
necessary, depending on information and data we develop or receive from
interested stakeholders. We do not feel that initially having no or
small amounts of Medicare claims data for new brachytherapy sources or
established sources with lower volumes than other sources in our claims
data is a compelling argument to deviate from our prospective payment
methodology and pay for some sources at charges adjusted to cost while
others would be paid prospectively based on their median cost. We note
that we had no additional claims for ytterbium-169 for this final rule
with comment period, beyond the three likely incorrectly coded CY 2006
claims discussed in the proposed rule.
After consideration of the public comments received, we are
finalizing our proposal, without modification, to 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 policy will apply to the existing HCPCS code
C2637 for the ytterbium-169 source, as well, which is assigned status
indicator ``B'' in Addendum B to this final rule with comment period.
We received no additional information on this source in comments to the
CY 2008 proposed rule. In the event that we receive information
regarding the costs and current marketing of HCPCS code C2637, we will
consider changing its status indicator to ``K'' in a quarterly OPPS
update and setting a prospective payment rate for this source.
Comment: Several commenters requested that CMS implement the APC
Panel's March 2007 recommendation to edit and return for correction
claims that contain a HCPCS code for a separately paid drug or device
without a HCPCS code assigned to a procedural APC.
Response: We note that brachytherapy treatment services are paid
separately from brachytherapy sources and do not have the costs of the
brachytherapy sources packaged into the payment for the associated
treatment services. While we encourage hospitals to code correctly in
accordance with all CPT, CMS, and local contractor guidance, in general
we have historically implemented claims processing edits under the OPPS
when we believe that these edits help ensure complete claims data for
ratesetting. In the case of OCE edits for drugs and devices, including
brachytherapy sources, which are separately paid, it is unclear to us
that these edits would improve our claims data for median cost
calculation because the items receive separate payment and do not
result in multiple procedure claims when they are reported. We also
understand that there may be some clinical or operational circumstances
that could result in a hospital submitting an OPPS claim that only
reported a separately paid drug or device, and we would not want to
delay a hospital's ability to submit a claim timely because of claims
edits that do not have the potential to improve the accuracy of OPPS
ratesetting. Therefore, we are not adopting this APC Panel
recommendation for broad claims processing edits.
Comment: A few commenters recommended that CMS revise the
definition of brachytherapy sources to include all ``brachytherapy
sources,'' without limitation to a device of brachytherapy.
Response: We finalized our definition of a source of brachytherapy
in the CY 2007 final rule with comment period (71 FR 68113) in the
context of current medical practice and with regard to the statutory
language. We considered all comments, including some of the same
arguments presented in comments to the CY 2008 proposed rule. We made
no proposal to change this definition in our CY 2008 proposed rule and
are not considering any changes to the established definition at this
time.
Comment: One commenter opposed the proposal to include the costs of
brachytherapy sources in the budget neutrality formula, if CMS adopted
the proposal to pay for the sources on a prospective basis. The
commenter believed that brachytherapy treatment is very costly and
inclusion of the costs would decrease the payment for other OPPS
services. The commenter also claimed that CMS has not factored into
payment for brachytherapy treatment the special handling costs of
radioactive materials.
[[Page 66787]]
Response: We take into account the estimated costs of brachytherapy
sources under the methodology of charges adjusted to cost in
calculating budget neutrality for the OPPS and have continued to do so
under the prospective payment methodology for the sources that we are
finalizing for CY 2008. The costs related to supervision, handling, and
loading of brachytherapy sources are, in fact, also considered under
the OPPS. As we have previously instructed, these costs are to be
included by hospitals on claims in one of two ways, either reported as
a separate charge using CPT code 77790 (Supervision, handling, loading
of radiation source) or included in the charge reported with the HCPCS
procedure code(s) for application of the radiation source. Reporting in
either of these ways results in the costs of special handling being
packaged into payments for brachytherapy treatment procedures.
VIII. OPPS Drug Administration Coding and Payment
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 (HOPD):
Q0081 (Infusion therapy, using other than chemotherapeutic
drugs, per visit)
Q0083 (Chemotherapy administration by other than infusion
technique only, (EG subcutaneous, Intramuscular, Push), 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, at that time, 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 HOPD, without regard to
whether or not the CPT code would receive a separate APC payment during
OPPS claims processing.
While hospitals just began 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 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 6 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.
For CY 2007, as a result of comments to our proposed rule and
feedback from the hospital community and the APC Panel, we implemented
the full set of CPT codes, including the concepts of initial,
sequential and concurrent. In addition, the CY 2007 update process
offered us the first opportunity to consider data gathered from the use
of CY 2005 CPT codes for purposes of ratesetting. For CY 2007, we used
CY 2005 claims data to implement a six-level APC structure for drug
administration services. We assigned all CY 2007 HCPCS codes for drug
administration services to six new drug administration APCs (as listed
in Table 34 of the CY 2007 OPPS/ASC final rule with comment period),
with payment rates based on median costs for the APCs as calculated
from CY 2005 claims data. In that final rule with comment period, we
provided a crosswalk that illustrated how we performed our annual
payment rate update methodology for these services using CY 2005 data.
As indicated in the CY 2007 OPPS/ASC final rule with comment period
(71 FR 68122), because the newly recognized CPT codes discriminated
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 were paid
based on the costs of their predecessor HCPCS codes until updated data
were available for review.
B. Coding and Payment for Drug Administration Services
During the March 2007 APC Panel meeting, the APC Panel recommended
that CMS pay separately for CPT code 90768 (Intravenous infusion, for
therapy, prophylaxis, or diagnosis (specify substance or drug);
concurrent infusion (list separately in addition to code for primary
procedure)) at the same rate as CPT code 90767 (Intravenous infusion,
for therapy, prophylaxis, or diagnosis (specify substance or drug);
additional sequential infusion, up to 1 hour (list separately in
addition to code for primary procedure)). We proposed to continue to
package payment for CPT code 90768 for CY 2008.
Comment: In addition to the APC Panel's recommendation to unpackage
CPT code 90768, a few commenters also requested that CMS provide
separate payment for it in CY 2008.
Response: As we discuss in section II.A.4.e. of this final rule
with comment period, in deciding whether to package a service or pay
for it separately, we consider a variety of factors, including
[[Page 66788]]
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. CPT code 90768, by definition, is always provided in
association with other intravenous infusions. As we discussed in the CY
2007 OPPS/ASC final rule with comment period (71 FR 68122), CPT code
90768 was first introduced in the CY 2007 OPPS and, consistent with our
established ratesetting methodology, we do not anticipate OPPS hospital
claims data from CY 2007 to be available for ratesetting purposes until
CY 2009. In addition, as noted in the CY 2008 OPPS/ASC proposed rule
(72 FR 42751), because the services identified with CPT code 90768 were
provided in previous years, we determined that these costs are already
represented in our currently available hospital claims data. Payment
for these services was provided in previous years through the billing
of more general drug administration codes. Although more exhaustive
codes for drug administration services are now available, all of these
services were paid under the OPPS in previous years.
As data are not available for all current CPT codes for drug
administration services for purposes of CY 2008 ratesetting, and as we
believe that the costs for the drug administration services identified
by CPT code 90768 are included in our hospital claims data used for
ratesetting purposes, we are not accepting the APC Panel's
recommendation nor the commenters' request to provide a separate APC
payment for this service. Furthermore, we describe in section II.A.4.
of this final rule with comment period our CY 2008 packaging approach
for certain (non-drug administration) services. We believe that
continuing to package payment for CPT code 90768 is consistent with
these broader efforts. Therefore, we are finalizing our proposal to
assign status indicator ``N'' to CPT code 90768 for CY 2008.
For CY 2008, we examined CY 2006 claims data available for the
proposed rule and continued to believe the CY 2007 drug administration
APC configuration reflects clinical and resource homogeneous groupings
of procedures. We noted in the proposed rule (72 FR 42751) that there
is a violation of the 2 times rule in APC 0438 (Level III Drug
Administration) as proposed for CY 2008. (For additional information on
the 2 times rule, we refer readers to section III.B. of this final rule
with comment period.) For this CY 2008 OPPS/ASC final rule with comment
period, this 2 times violation continues to exist based upon updated
data. The violation is related to the comparatively low median cost of
CPT code 90773 (Therapeutic, prophylactic or diagnostic injection
(specify substance or drug); intra-arterial) for which we have a
significantly greater number of CY 2006 single claims available for
ratesetting than in previous years. The CY 2005 predecessor code for
this service, CPT code 90783 (Therapeutic, prophylactic or diagnostic
injection (specify material injected); intra-arterial), had a higher
median cost that was more similar to the costs of other services also
assigned to APC 0438. We continue to believe that this intra arterial
injection procedure is similar from both clinical and hospital resource
perspectives to the related intravenous push injection procedures that
are assigned to the same clinical APC and, therefore, we proposed to
except APC 0438 from the 2 times rule for CY 2008.
We did not receive any public comments on this proposal. Therefore,
for CY 2008, we are finalizing our proposed exception to the 2 times
rule for APC 0438, without modification.
In the proposed rule, we also continued to ask hospitals to report
all CPT drug administration codes, and indicated that we expect
hospitals to report CPT codes consistently with CPT coding guidelines
and applicable instructions.
Comment: Several commenters expressed appreciation for CMS'
proposal to continue the CPT coding structure for drug administration
services for CY 2008. These commenters noted that the changes made to
coding and payment for these services in past years has put a burden on
hospitals to train staff on frequent changes. Other commenters
expressed frustration over complex CPT coding for drug administration
services, noting that reporting requirements placed an unreasonable
burden on hospitals to code correctly and increased hospital staffing
needs. One commenter suggested that CMS return to simpler coding, such
as the historical single per-episode-of-care code to report a
``nonchemotherapy infusion.'' The commenter noted that this methodology
aligns with CMS' efforts to increase packaging for services and
simplifies hospital coding requirements.
Response: We appreciate hospitals' continuing efforts to work with
us to implement changes to drug administration coding and payment over
the past few years. We believe that our individual and collaborative
efforts to refine the codes used and ensure their accurate reporting
have led to a robust dataset that accurately reflects hospital
outpatient costs for these common services and results in appropriate
payment. We understand that it requires significant hospital resources
to ensure proper coding for drug administration services, and hospitals
have worked diligently over the past several years to ensure that CMS'
data appropriately reflect drug administration services provided in the
HOPD. While we recognize the continued efforts that are necessary to
accurately document and report drug administration services using CPT
codes, we believe that hospitals have had sufficient experience with
these codes, first for non Medicare insurers in CY 2006 and then for
the Medicare OPPS in CY 2007, that the initial confusion corresponding
to the new concepts of ``initial,'' ``sequential,'' and ``concurrent''
has subsided.
We agree with the commenter that a return to a single episode-of-
care payment could align with the OPPS shift toward larger payment
bundles, but we believe that a change in our approach toward drug
administration payment would be premature at this time. While
additional packaging for drug administration services could be
warranted in a prospective payment system such as the OPPS in a
movement toward encounter-based or episode-based payment, hospital
stakeholders continue to express their preference for a single set of
drug administration codes for use by all insurers. Currently, the CPT
drug administration codes sufficiently meet the needs of non-Medicare
insurers and Medicare. We do not have any reason to believe that
hospitals generally would want to implement a per-episode-of-care set
of drug administration codes for use only under the OPPS, nor do we
have an operational need for such codes. Therefore, we are finalizing
our proposal, without modification, to recognize all active CY 2008 CPT
codes for drug administration services under the CY 2008 OPPS.
Comment: One commenter requested that CMS review payment
methodologies for drug administration services across the hospital
outpatient and physician's office settings. This commenter suggested
that the OPPS consider implementing a methodology similar to the
physician's office payment methodology, basing payment rates on the
time and resource utilization required by the service. The commenter
believed that standardizing payment rates across sites of care would
eliminate site of service differentials
[[Page 66789]]
and allow beneficiaries the option of receiving care in either setting.
Response: We understand that the commenter is concerned about
differences in payment methodologies and rates across ambulatory
settings when some of the same services are provided to Medicare
beneficiaries. Even though both settings use the standard CPT codeset
for drug administration services, the costs of providing these services
in one setting may not be the same as the costs in another setting. The
OPPS and the 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 under the OPPS according to prospectively established
payment rates that are related to the relative costs of hospital
resources for services, as calculated from claims data and Medicare
cost reports. The MPFS is a fee schedule that generally provides
separate payment for each individual component of a service, reflecting
the expected typical inputs into these services. The OPPS methodology
allows hospitals to actively contribute on an ongoing basis to the
ratesetting process through its annual updates and to influence future
payment rates for services by submitting correctly coded and accurately
priced claims for the services they provide.
Comment: A few commenters recommended that CMS create two new Level
II HCPCS codes for IVIG infusion services, one for the first hour and
the other for additional hours of infusion. The commenter cited
additional complexities associated with IVIG infusion and increased
chances of adverse events that are not fully captured in the CPT codes
currently reported by hospitals for these infusions.
Response: While we acknowledge these concerns regarding IVIG
administration, we believe that the current CPT coding structure and
OPPS payment rates adequately provide for the possible complexities
associated with IVIG administration services. Hospital costs for IVIG
administration are taken into account during the ratesetting process,
as claims for IVIG administration are used in that process for the
pertinent CPT codes. Hospitals continue to note their strong preference
for reporting CPT codes for drug administration services, as opposed to
OPPS-specific Level II HCPCS codes that could be more specifically
developed for certain services. In addition, in view of the shift
toward larger payment bundles under the OPPS, we do not believe it
would be appropriate to create even more specific coding for drug
administration services than is available through the codeset developed
by the CPT Editorial Panel.
As stated earlier, after consideration of the public comment
received, we are finalizing our proposal, without modification, to
recognize all active CY 2008 CPT codes for drug administration services
under the OPPS for CY 2008. In addition, we are finalizing our
proposal, without modification, to assign status indicator ``N'' to CPT
code 90768 for CY 2008.
IX. Hospital Coding and Payments for Visits
A. Background
Currently, CMS instructs hospitals to use the CY 2007 CPT codes, as
well as six HCPCS codes that became effective January 1, 2007, to
report clinic and emergency department visits, and critical care
services on claims paid under the OPPS. The codes are listed below in
Table 38. These codes are unchanged for CY 2008.
Table 38.--CY 2007 CPT Evaluation and Management (E/M) and Level II
HCPCS Codes Used To Report Clinic and Emergency Department Visits
------------------------------------------------------------------------
HCPCS code Descriptor
------------------------------------------------------------------------
Clinic Visit HCPCS 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 HCPCS 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).
G0380............................. Type B emergency department visit
(Level 1).
G0381............................. Type B emergency department visit
(Level 2).
G0382............................. Type B emergency department visit
(Level 3).
G0383............................. Type B emergency department visit
(Level 4).
G0384............................. Type B emergency department visit
(Level 5).
------------------------------------------------------------------------
[[Page 66790]]
Critical Care Services HCPCS Codes
------------------------------------------------------------------------
99291............................. Critical care, evaluation and
management of the critically ill or
critically injured patient; first
30-74 minutes.
99292............................. Each additional 30 minutes.
G0390............................. Trauma response associated with
hospital critical care services.
------------------------------------------------------------------------
Presently, there are three types of visit codes to describe three
types of services: clinic visits, emergency department visits, and
critical care services. 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 that specifically
apply to the reporting of visits to Type A emergency departments on or
after January 1, 2007, as discussed in further detail later in this
section. We established five new Level II HCPCS codes to report visits
to Type B emergency departments beginning in CY 2007 because there were
no CPT codes at that time that fully described services provided in
this type of facility. 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 addition to reporting critical
care services, hospitals may utilize G0390 (Trauma response team
associated with hospital critical care service) for the reporting of a
trauma response in association with critical care services.
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 E/M codes were defined to reflect the activities of
physicians and do not necessarily fully describe the range and mix of
services provided by hospitals during visits of clinic and emergency
department patients and critical care encounters. In the April 7, 2000
OPPS final rule with comment period (65 FR 18434), we 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 hospitals 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.
Critical care services are considered to be outpatient visits, and
our current payment policy for trauma activation ties separate payment
to the reporting of hospital critical care services. In the CY 2008
OPPS/ASC proposed rule, we did not propose to change our OPPS payment
policy for critical care services for CY 2008. Our CY 2008 proposed and
final policies for payment for trauma activation are described in
section II.A.4. of this final rule with comment period.
B. Policies for Hospital Outpatient Visits
1. Clinic Visits: New and Established Patient Visits and Consultations
As discussed earlier, 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 fully describe the
range and mix of services provided by hospitals during visits of clinic
and emergency department patients. While awaiting the development of a
national set of guidelines, we have advised hospitals 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 CY 2007 OPPS/ASC proposed rule
(71 FR 49607), we proposed to establish five new codes to replace
hospitals' reporting of the CPT clinic visit E/M codes for new and
established patients listed earlier in Table 38. In the CY 2007 OPPS/
ASC final rule with comment period (71 FR 68127 through 68128), we
specified that we would not create new codes to replace existing CPT E/
M codes for reporting hospital visits until national guidelines were
developed, in response to commenters who were concerned about
implementing hospital-specific Level II HCPCS codes without national
guidelines. We also discussed our intention to reconsider whether G-
codes would be appropriate for the OPPS once national guidelines were
established.
In that same CY 2007 final rule with comment period (71 FR 68138),
we finalized our proposal to make payment for clinic visits at five
payment rates, rather than three payment rates. Prior to CY 2007, under
the OPPS, outpatient visits provided by hospitals were paid at three
payment levels for clinic visits, even though hospitals reported five
resource-based coding levels of clinic visits using CPT E/M codes.
Because the three payment rates for clinic visits were based on five
levels of CPT codes, in general the two lowest levels of CPT codes
(Levels 1 and 2) were assigned to the low-level visit APC and the two
highest levels of CPT codes (Levels 4 and 5) were assigned to the high-
level visit APC. The single middle level CPT code (Level 3) was
assigned to the mid-level visit APC. Historical hospital claims data
have generally reflected significantly different median costs for the
two levels of services assigned to the low- and high-level visit APCs.
We noted that payment at only three levels might not be the most
accurate method of payment for those very common hospital levels of
visits that clearly demonstrate differential hospital resources.
Consequently, for the CY 2007 OPPS, we mapped the data from the CY 2005
CPT E/M codes and other HCPCS codes assigned previously to the three
clinic visit APCs to five new clinic visit APCs to develop median costs
for these APCs. We mapped the CPT E/M codes and other HCPCS codes to
the clinic visit APCs based on their median
[[Page 66791]]
costs and clinical homogeneity considerations. Table 50 of the CY 2008
OPPS/ASC proposed rule, which is reprinted below as Table 39, includes
the median costs based on CY 2006 claims data processed through
December 31, 2006, and displays the proposed HCPCS codes and APC median
costs at the five payment levels that we proposed for the CY 2008 OPPS.
Table 39.--Proposed Rule Assignment of Claims Data From CY 2006 CPT E/M Level II HCPCS Codes To Visit APCs for
CY 2008
----------------------------------------------------------------------------------------------------------------
APC
Proposed CY service
CY 2008 APC title CY 2008 2008 APC frequency HCPCS Short descriptor
APC median (in code
millions)
----------------------------------------------------------------------------------------------------------------
Level 1 Hospital Clinic Visits...... 0604 $52.72 3.8 92012 Eye exam established pat.
99201 Office/outpatient visit, new
(Level 1).
99211 Office/outpatient visit, est
(Level 1).
99241 Office consultation (Level
1).
G0101 CA screen; pelvic/breast
exam.
G0245 Initial foot exam pt lops.
G0379 Direct admit hospital
observ.
----------------------------------------------------------------------------------------------------------------
Level 2 Hospital Clinic Visits...... 0605 63.01 7.3 90862 Medication management.
92002 Eye exam, new patient
92014 Eye exam and treatment.
99202 Office/outpatient visit, new
(Level 2).
99212 Office/outpatient visit, est
(Level 2).
99213 Office/outpatient visit, est
(Level 3).
99242 Office Consultation (Level
2).
99243 Office Consultation (Level
3).
99431 Initial care, normal
newborn.
G0246 Followup eval of foot pt
lop.
G0344 Initial preventive exam.
M0064 Visit for drug monitoring.
----------------------------------------------------------------------------------------------------------------
Level 3 Hospital Clinic Visits...... 0606 85.96 2.9 92004 Eye exam, new patient.
99203 Office/outpatient visit, new
(Level 3).
99214 Office/outpatient visit, est
(Level 4).
99244 Office consultation (Level
4).
----------------------------------------------------------------------------------------------------------------
Level 4 Hospital Clinic Visits...... 0607 108.08 .8 99204 Office/outpatient visit, new
(Level 4).
99215 Office/outpatient visit, est
(Level 5).
99245 Office consultation (Level
5).
----------------------------------------------------------------------------------------------------------------
Level 5 Hospital Clinic Visits...... 0608 138.88 .08 99205 Office/outpatient visit, new
(Level 5).
G0175 OPPS service, sched team
conf.
----------------------------------------------------------------------------------------------------------------
In the CY 2007 OPPS/ASC proposed rule (71 FR 49617), we 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
patients. 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 3 years.'' To apply this definition to hospital visits, we
stated in the April 7, 2000 OPPS final rule with comment period (65 FR
18451) 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 with respect to the
hospital.
During CY 2006 and earlier, there was no payment difference between
new and established patient visits of the same level because both were
always mapped to the same clinical APC. However, hospital claims data
regarding the median costs of the specific CPT clinic visit E/M codes
consistently indicated that new patients were more resource-intensive
than established patients across all visit levels. The CY 2006 claims
data available for the CY 2008 rulemaking confirmed that the cost
difference between new and established patient visits increases as the
visit level increases.
Some commenters who responded to prior OPPS 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. On the other hand, other commenters
have noted, and CY 2005 and CY 2006 claims data have shown, that it may
be appropriate to continue using different codes for new and
established patients because of the observed median cost differences in
the claims data. During the March 2007 APC Panel meeting, the
Observation and Visit Subcommittee of the APC Panel discussed whether
the coding distinction between new and established patient visits was
necessary. Ultimately, the APC Panel
[[Page 66792]]
recommended that CMS eliminate the ``new'' and ``established'' patient
distinctions in the reporting of hospital clinic visits. During its
discussion, the APC Panel suggested that hospitals bill the appropriate
level clinic visit code according to the resources expended while
treating the beneficiary based on each hospital's internal guidelines.
The APC Panel also suggested that each hospital's internal guidelines
reflect resource cost differences (if a difference exists) between new
and established patients. For example, a visit that involves certain
interventions may be coded as Level 3 for a new patient and Level 2 for
an established patient. The APC Panel also made another recommendation,
which was contingent upon CMS adopting its recommendation to eliminate
the new and established patient distinction reporting requirement. The
APC Panel recommended that CMS map each of the five levels of
outpatient clinic visit codes (which do not distinguish between new and
established patients) to five separate APCs, thereby paying at five
payment rates. For example, the APC Panel recommended mapping the Level
1 patient visit to the Level 1 Clinic Visit APC, mapping the Level 2
patient visit to the Level 2 Clinic Visit APC, and mapping the Level 3
patient visit to the Level 3 Clinic Visit APC. In the CY 2008 proposed
clinic visit APC configuration, as indicated in Table 50 of the CY 2008
OPPS/ASC proposed rule (72 FR 42753), the APC level assignment did not
always correspond to the visit level described by each code. For
example, CPT code 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 code 99213 had a proposed rule
median cost of $65, we proposed to map this code to the Level 2 Clinic
Visit APC, which had a median cost of $63. The APC Panel indicated that
its recommendation would ensure that each visit level would receive its
own payment rate, rather than both the Level 2 and 3 patient visit
codes receiving the same payment rate.
In both the CY 2007 OPPS/ASC proposed and final rules (71 FR 49617
and 71 FR 68128, respectively), we solicited public comment on the
potential differences in hospital clinic resource consumption between
new and established patient visits. We received only a few comments
related to this distinction in response to the CY 2007 OPPS/ASC
proposed rule and even fewer comments in response to the CY 2007 OPPS/
ASC final rule with comment period. For CY 2008, because hospitals
would be reporting CPT E/M codes which distinguish between new and
established patients for clinic visits and because we saw meaningful
and consistent cost differences between visits for new and established
patients, we proposed to continue to recognize the CPT codes for new
and established patient clinic visits under the OPPS, consistent with
their CPT code descriptors. Further, we did not propose to adopt the
recommendation of the APC Panel to eliminate this differentiation for
the reasons noted. We proposed to reexamine whether the coding
distinction between new and established patient visits was necessary as
we further considered national guidelines. We continued to encourage
public comment about hospitals' experiences with assigning visit levels
to new and established patients according to their own internal
guidelines.
Table 51 of the CY 2008 OPPS/ASC proposed rule, which is reprinted
below as Table 40, lists the CY 2008 proposed median costs of new and
established patient clinic visit codes, which were based on CY 2006
claims data processed through December 31, 2006.
Table 40.--CY 2008 Proposed Median Costs of New and Established Patient
Visit CPT Codes
------------------------------------------------------------------------
CY 2008
CY 2008 new established
Clinic visit level patient visit patient visit
proposed proposed
median cost median cost
------------------------------------------------------------------------
Level 1................................. $56.08 $50.70
Level 2................................. 63.18 58.84
Level 3................................. 74.99 64.73
Level 4................................. 109.12 84.17
Level 5................................. 138.06 102.89
------------------------------------------------------------------------
Comment: Most commenters on the proposals requested that CMS
eliminate the need for hospitals to distinguish between new and
established patient visits because they found it cumbersome to bill a
different code for each type of visit. Specifically, the commenters
asked CMS not to implement new and established patient visit codes. The
commenters suggested that hospitals bill the appropriate code, based on
the resources expended in the visit. Several commenters suggested that
CMS require hospitals to bill the established patient visit code
exclusively and change the status of the new patient visit codes to
nonpayable. The commenters suggested setting the payment rate for the
established patient visit code at a blend of the new and established
patient visit rates. One commenter requested that both the new and
established patient visit codes remain payable, but that the OPPS pay
the same rate for the new and established patient visit, at each level,
an approach which would remove any financial incentive for reporting
one code instead of another. Several commenters supported the proposal
to continue requiring hospitals to distinguish between new and
established patient visits. Some of the commenters suggested that the
AMA create hospital-specific Category I CPT visit codes that do not
distinguish between new and established patient visits, as appropriate
for reporting hospital resource use.
Response: Because hospitals will be reporting CPT codes for CY 2008
and we continue to observe significant cost differences between new and
established patient visits of the same level, we will continue to
recognize new and established patient visit codes under the CY 2008
OPPS, consistent with their CPT code descriptors. We agree with the
commenters that it could be simpler and less burdensome from a coding
perspective if hospitals only needed to report one set of codes and
could report code levels that reflected their resources used, rather
than distinguishing between new and established patient visits.
However, in the absence of hospital-specific CPT codes for the
reporting of visits in the HOPD, hospitals should continue to
distinguish between new and established patient visits, consistent
[[Page 66793]]
with their CPT code descriptors. We will reexamine whether the coding
distinction between new and established patient visits is necessary as
we continue to explore national guidelines.
Comment: Several commenters requested that CMS define a new patient
as a patient who does not have a hospital medical record, rather than a
patient who does not have a medical record that was created within the
past 3 years. The commenters cited the definitions of new and
established patients that we discussed in the CY 2007 OPPS/ASC final
rule with comment period (71 FR 68128) where CMS stated that if the
patient had a hospital medical record that was created within the past
3 years, that patient would be considered an established patient to the
hospital. Several of the commenters believed that the ``new'' patient
definition described in the April 7, 2000 OPPS final rule with comment
period (65 FR 18451) did not require hospitals to determine if a
medical record had been created for the patient within the past 3
years.
Response: We note that we neither proposed a change to the
definitions of new and established patient visits in the CY 2008 OPPS/
ASC proposed rule nor solicited comment on the definitions of new and
established patient visits. While several commenters asked us to revise
these definitions, we are reluctant to make these changes without
hearing additional perspectives from the larger hospital community.
Therefore, we are specifically soliciting comment on the definitions of
new and established patient visits in the HOPD.
For CY 2008, we are finalizing our proposal, without modification,
to continue to recognize the CPT codes for new and established patient
clinic visits under the OPPS, consistent with their CPT code
descriptors. Further, we are not adopting the recommendation of the APC
Panel to eliminate this differentiation for the reasons noted above. We
continue to encourage hospitals to submit comments regarding their
experiences with assigning visit levels to new and established patients
according to their own internal guidelines. In addition, as noted
above, we are specifically soliciting comment on the definitions of new
and established patient visits in the HOPD.
As noted above, the APC Panel also recommended that CMS map each
level of patient visits to its corresponding APC, thereby paying at
five payment levels. The APC Panel members noted that this mapping
system would eliminate any payment incentive to distinguish between new
and established patients, but would ensure five payment levels.
In the CY 2008 OPPS/ASC proposed rule, we proposed to maintain the
CY 2007 mapping for the clinic visit codes for established patients. As
indicated in Table 50 of the proposed rule, which is reprinted earlier
as Table 39 in this final rule with comment period, we proposed to map
the Level 1 established patient visit to the Level 1 Clinic Visit APC,
which resulted in the Level 1 Clinic Visit APC containing both the
Level 1 new and established patient visit codes, in accordance with the
APC Panel's recommendation. Similarly, we proposed to map both the
Level 2 new and established patient visit codes to the Level 2 Clinic
Visit APC. However, we also proposed to map the Level 3 established
patient visit code to the Level 2 Clinic Visit APC because our cost
data indicated that the costs associated with a Level 3 established
patient visit most closely resembled the costs associated with the
Level 2 Clinic Visit APC and the Level 2 new and established patient
visits. If CPT code 99213 for an established Level 3 clinic visit were
mapped to the Level 3 Clinic Visit APC, which had a proposed median
cost of approximately $86, we would significantly overpay CPT code
99213 every time it was billed. Therefore, we proposed to map the Level
3 new patient visit to the Level 3 Clinic Visit APC, consistent with
the APC Panel's recommendation. We also proposed to map the Level 4
established patient visit to the Level 3 Clinic Visit APC, and the
Level 5 established patient visit to the Level 4 Clinic Visit APC. The
only CPT E/M code that we proposed to map to the Level 5 Clinic Visit
APC for CY 2008 payment was the Level 5 new patient visit. These APC
assignments which were proposed for CY 2008 consistent with their CY
2007 APC assignments, were determined for each HCPCS code based on CY
2006 claims data available for CY 2008 ratesetting and clinical
considerations. In the CY 2008 OPPS/ASC proposed rule, we indicated
that we were not persuaded by the APC Panel's recommendation, which
would have required us to ignore significant cost differences based on
resource data that were clinically consistent and, therefore, we did
not propose to map each code to its corresponding level APC.
In the proposed rule, we noted that historical cost data for these
frequently provided services were extremely consistent. In addition,
from a clinical perspective, we believed that in some cases, in the
context of a five-level structure for visit reporting, the hospital
resources required for a given visit level might only be slightly
different from those used for a visit that was one level higher or
lower. For example, it was not surprising that particularly among
visits for established patients in the middle of the range, such as a
Level 2 established patient visit and a Level 3 established patient
visit, the hospital resource costs calculated from claims data were
similar because these patients would often utilize reasonably
comparable hospital resources.
In the proposed rule, we performed data analyses using proposed
rule data to determine how the median costs of the clinic visit APCs
would have changed if we fully adopted the APC Panel's recommendation,
and mapped all of the new and established patient visit codes to the
corresponding level of clinic visit APC. Our results were shown in
Table 52 of the CY 2008 OPPS/ASC proposed rule, which is reprinted
below as Table 41.
Table 41.--CY 2008 Median Cost Comparison of Clinic Visit APCs in Two
Different Configurations Using CY 2006 Proposed Rule Data
------------------------------------------------------------------------
APC Median APC Median
cost in the cost in the
APC proposed CY recommended
2008 APC panel
configuration configuration
------------------------------------------------------------------------
Level 1 Clinic Visit.................... $53 $53
Level 2 Clinic Visit.................... 63 60
Level 3 Clinic Visit.................... 86 66
Level 4 Clinic Visit.................... 108 88
Level 5 Clinic Visit.................... 139 110
------------------------------------------------------------------------
[[Page 66794]]
In the CY 2008 OPPS/ASC proposed rule, we concluded that the APC
median cost distribution did not improve when each new and established
patient visit code was mapped to its corresponding level of APC. In
fact, the APC Panel's recommended configuration resulted in lower
payment rates for the Levels 2 through 5 Clinic Visit APCs, and an
identical payment rate for the Level 1 Clinic Visit APC because our
proposed mapping and the APC Panel's recommendation for this APC were
the same. In general, under the OPPS, we rely on resource cost data
calculated from hospital claims data to determine appropriate APC
mapping of HCPCS codes, and to set payment rates. While we acknowledged
in the proposed rule that it might be more predictable for hospitals to
receive the same payment rate for new and established patients of the
same visit level, robust cost data clearly indicated that this would
not be the most accurate payment method. Historical hospital cost data
demonstrated that new patient visits were more costly than established
patient visits of the same level, a finding that was consistent with
the perspective of our medical advisors. Because we proposed that
hospitals continue to use CPT E/M codes to report clinic visits for CY
2008, including separate codes for new and established patients, we saw
no reason to adjust the clinic visit APC configurations. Therefore, for
CY 2008, we proposed to map the CPT E/M codes and other Level II HCPCS
codes to the Clinic Visit APCs as configured in Table 50 of the
proposed rule, and not fully adopt the APC Panel's recommendation to
map each code to its corresponding APC level. We indicated that we
would re-examine this issue using the claims data for CY 2009 OPPS
ratesetting, and would also reconsider whether this mapping is
appropriate in the future as we continue to work on developing national
guidelines.
Comment: A few commenters opposed the proposal to map the CPT E/M
codes and other Level II HCPCS codes to the Clinic Visit APCs based on
resource cost and clinical homogeneity and stated that it made sense
for each code to map to the corresponding APC level. For example, the
commenters requested that the Level 3 new and established patient visit
codes both map to the Level 3 Visits APC.
Response: While we understand that it would be more straightforward
if each code mapped to its corresponding APC level, we did not receive
any compelling reasons to ignore significant cost differences based on
robust resource data that are clinically consistent. We note that we
will not be adopting the APC Panel's recommendation that each code map
to its corresponding APC level for CY 2008.
We are finalizing the proposed Clinic Visit APC configuration, with
minor modification for CY 2008. Specifically, we are mapping the CPT E/
M codes and other Level II HCPCS to the appropriate Clinic Visit APCs,
based on resource costs. Several HCPCS codes more appropriately map to
different Clinic Visit APCs than proposed in Table 50 as a result of
analyzing the full year final rule resource cost data. In addition,
several other HCPCS codes for services resembling visits have been
assigned to the Clinic Visit APCs for CY 2008. We refer readers to
Addendum B to this final rule with comment period for the complete
listing of visit codes and their placements for CY 2008. Furthermore,
as discussed in detail in section II.A.4.c.(7) of this final rule with
comment period, in some cases when high-level visits are reported with
a new or established patient Level 5 CPT E/M code, a Level 4 or 5
emergency department visit CPT code, a critical care CPT code, or
direct admission to observation HCPCS code in association with 8 or
more hours of nonsurgical observation services, we will provide a
single payment in CY 2008 for the encounter through one of two new
composite APCs, specifically APCs 8002 (Level I Extended Assessment and
Management) and 8003 (Level II Extended Assessment and Management).
The APC Panel also recommended that CMS not recognize the CPT
consultation codes: CPT code 99241 (Office consultation for a new or
established patient (Level 1)), CPT code 99242 (Office consultation for
a new or established patient (Level 2)), CPT code 99243 (Office
consultation for a new or established patient (Level 3)), CPT code
99244 (Office consultation for a new or established patient (Level 4)),
and CPT code 99245 (Office consultation for a new or established
patient (Level 5)). The APC Panel recommended that CMS instruct
hospitals to build consultation services into their internal hospital
guidelines related to reporting outpatient clinic visit levels based on
the complexity and resources used for these outpatient visits.
CPT defines a consultation as ``a type of service provided by a
physician whose opinion or advice regarding evaluation and/or
management of a specific problem is requested by another physician or
other appropriate source.'' CPT recognizes two subcategories of
consultations, specifically office or other outpatient and inpatient
consultations, although only the office consultations would be
applicable under the OPPS. As we observed in the CY 2008 OPPS/ASC
proposed rule, the differentiation of consultations from new and
established patient clinic visits would appear to be clinically
unnecessary under the OPPS in order to provide proper OPPS payment for
hospital outpatient visits.
In the CY 2007 OPPS/ASC final rule with comment period (71 FR
68128), we stated our belief that it might be unnecessary for hospitals
to report consultation CPT codes if either a new or established patient
visit code accurately described the service provided. We stated that we
were particularly interested in hearing whether consultation codes were
a useful measure of hospital resource use under the OPPS, and how
consultation visits were different, from a hospital resource
perspective, from new patient visits and established patient visits. We
observed that we did not want to create an incentive for hospitals to
bill a consultation code instead of a new or established patient code
because we did not believe that consultation codes necessarily
reflected different resource utilization than either new or established
patient codes (71 FR 68138). Therefore, for CY 2007, we finalized a
payment policy that assigned the consultation code to the same clinical
APC as the established patient visit code for each level of service.
For example, CPT code 99242, the Level 2 consultation code, was mapped
to APC 0605 (Level 2 Clinic Visits), which was where CPT code 99212,
the Level 2 established patient code, was also assigned for CY 2007.
Moving the consultation codes to the same APCs as the corresponding
established patient visit codes eliminated any incentive for hospitals
to bill a consultation code instead of a new or established patient
code.
[[Page 66795]]
Table 42.--CY 2008 Median Costs and Frequencies of CPT Consultation
Visit Codes Using CY 2006 Proposed Rule Data
------------------------------------------------------------------------
Code descriptor Median cost Frequency
------------------------------------------------------------------------
Level 1 Consultation.................... $66.48 62,000
Level 2 Consultation.................... 65.78 73,000
Level 3 Consultation.................... 81.95 155,000
Level 4 Consultation.................... 109.96 176,000
Level 5 Consultation.................... 139.61 94,000
------------------------------------------------------------------------
Consultation services were provided with much less frequency than
all levels of established patient visits and low-level new patient
visits in CY 2006 but were provided more frequently than high-level new
patient visits. The median costs for consultation codes were generally
similar to, or slightly higher than, the corresponding median costs of
the same level of new patient visits.
Aside from the APC Panel's recommendation, we received a few public
comments on the CY 2007 OPPS/ASC final rule related to this issue. In
the CY 2008 OPPS/ASC proposed rule, we noted our continued belief that
consultation codes were unnecessary and superfluous in the hospital
outpatient setting because hospitals could appropriately bill either a
new or established patient visit code, instead of a consultation code,
as appropriate in these cases. In the interest of simplifying billing,
for CY 2008, we proposed to assign status indicator ``B'' to the
consultation codes (that is, not paid under the OPPS), and instructed
hospitals to bill a new or established visit code instead of an office
consultation code, thereby adopting the APC Panel's recommendation not
to recognize these consultation codes. As appropriate, hospitals could
build consultation services into their internal hospital guidelines
related to reporting clinic visit levels, based on the complexity and
resources used for these visits.
Comment: Many commenters supported the proposal to change the
status of the consultation codes so that they are no longer recognized
under the OPPS. The commenters stated that this would simplify
outpatient hospital billing, and remove the option of reporting
unnecessary codes. A few commenters requested that the consultation
codes continue to be recognized under the OPPS because of the
administrative burden involved with analyzing each consultation to
determine if the visit should be new or established. In addition, the
commenters noted that there is a resource cost difference between
consultations and new and established patient visits. The commenters
stated that the cognitive intensity and the time to fully establish a
diagnosis and a treatment plan for consultation types of visits are
much greater than that of established patient visits.
Response: We agree with the commenters who requested that we
finalize our proposal not to recognize consultation codes under the
OPPS for CY 2008. As described above, we do not believe consultation
codes are a useful or necessary indicator of hospital resource use
under the OPPS. The commenters who requested that CMS continue to
recognize consultation codes may have been measuring physician resource
use, rather than hospital resource use. In addition, if consultation
services are more resource-intensive than established patient visits of
the same level, our proposal would permit hospitals to factor this into
their internal hospital guidelines that would determine the appropriate
level of established patient visit to report.
In summary, we are finalizing our CY 2008 proposal, without
modification, that hospitals continue to use CPT codes to bill for
clinic visits, and to distinguish between new and established patient
visits. For CY 2008, the CPT codes for new and established visits will
continue to be payable under the OPPS, but we will reconsider in the
future whether there should be a distinction between new and
established patient visits as we continue to work on developing
national guidelines. In the meantime, we will assign these clinic
visits to different levels of Clinic Visit APCs based on the costs we
observe from historical hospital claims data. For CY 2008, we are also
finalizing our proposal, without modification, to change the status of
the consultation codes so that these codes are no longer recognized for
payment under the OPPS.
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.'' Prior to CY
2007, under the OPPS we restricted the billing of emergency department
CPT codes to services furnished at facilities that met this CPT
definition. Facilities open less than 24 hours a day should not have
reported the emergency department CPT 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 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
(COBRA), Pub. L. 99-272.
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
[[Page 66796]]
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.
In the CY 2008 OPPS/ASC proposed rule, we reiterated our belief
that every emergency department that meets the CPT definition of
emergency department also qualifies as a dedicated emergency department
under EMTALA. However, we indicated that we were aware that there are
some departments or facilities of hospitals that meet the definition of
a dedicated emergency department 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 dedicated emergency department 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 did not meet the CPT
requirements for reporting emergency visit E/M codes, prior to CY 2007,
these facilities were required to bill clinic visit codes for the
services they furnished under the OPPS. We had no way to distinguish in
our hospital claims data the costs of visits provided in dedicated
emergency departments that did not meet the CPT definition of emergency
department from the costs of clinic visits.
Prior to CY 2007, some hospitals requested that they be permitted
to bill emergency department visit codes under the OPPS for services
furnished in a facility that met the CPT definition for reporting
emergency department visit E/M codes, except that they were not
available 24 hours a day. These hospitals believed that their resource
costs were more similar to those of emergency departments that met the
CPT definition than they were to the resource costs of clinics.
Representatives of such facilities argued that emergency department
visit payments would be more appropriate, on the grounds that their
facilities treated patients with emergency conditions whose costs
exceeded the resources reflected in the clinic visit APC payments, even
though these emergency departments were not available 24 hours per day.
In addition, these hospital representatives indicated that their
facilities had EMTALA obligations and should, therefore, be able to
receive emergency department visit payments. While these emergency
departments may have provided a broader range and intensity of hospital
services, and required significant resources to assure their
availability and capabilities in comparison with typical hospital
outpatient clinics, the fact that they did not operate with all
capabilities full-time suggested that hospital resources associated
with visits to emergency departments or facilities available less than
24 hours a day might not be as great as the resources associated with
emergency departments or facilities that were available 24 hours a day,
and that fully met 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, in the CY
2007 OPPS/ASC final rule with comment period (71 FR 68132), we
finalized a set of five G-codes for use by hospitals to report visits
to all entities that meet the definition of a dedicated emergency
department under the EMTALA regulations in Sec. 489.24, but that are
not Type A emergency departments, as described in Table 43 below. These
codes are called ``Type B emergency department visit codes.'' We
believed the creation of G-codes for Type B emergency departments was
necessary because there were no CPT codes that fully described 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. In that final rule, we explained that these new G-codes
would 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 (71 FR 68132).
Table 43.--CY 2007 Final Level II 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 visit... Level 1 hospital emergency 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 visit... Level 2 hospital emergency 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).
[[Page 66797]]
G0382..................... Lev 3 hosp type B ED visit... Level 3 hospital emergency 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).
G0383..................... Lev 4 hosp type B ED visit... Level 4 hospital emergency 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 5 hosp type B ED visit... Level 5 hospital emergency 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 assigned the five new Type B emergency department
visit codes for services provided in a Type B emergency department to
the five newly-established Clinic Visit APCs, 0604, 0605, 0606, 0607,
and 0608 (71 FR 68140). This payment policy for Type B emergency
department visits was similar to our previous policy, which required
services furnished in emergency departments that had an EMTALA
obligation, but did 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 required
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, we believed the reporting of specific G-codes for emergency
department visits provided in Type B emergency departments would permit
us to specifically collect, and analyze the hospital resource costs of
visits to these facilities in order to determine if in the future a
proposal for an alternative payment policy might be warranted. We
expected hospitals to adjust their charges appropriately to reflect
differences in Type A and Type B emergency departments. We noted that
the OPPS rulemaking cycle for CY 2009 would be the first year that we
would have cost data for these new Type B emergency department HCPCS
codes available for analysis.
In the CY 2007 OPPS/ASC proposed rule (71 FR 49609), 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 a dedicated emergency
department, 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 were called
``Type A emergency visit codes'' and were proposed to replace
hospitals'' reporting of the CPT emergency department visit E/M codes.
Our intention was to allow hospital-based emergency departments or
facilities that were historically appropriately reporting CPT emergency
department visit E/M codes to bill these new Type A emergency
department visit codes. In the CY 2007 OPPS/ASC final rule with comment
period (71 FR 68132), we postponed finalizing G codes to replace CPT
codes for Type A emergency department visits until national guidelines
are established, and stated that we would again consider their possible
utility once national guidelines are adopted. However, for CY 2007, we
finalized the definition of Type A emergency departments to distinguish
them from Type B emergency departments. For CY 2007 (71 FR 68140), we
assigned the five CPT E/M emergency department visit codes for services
provided in Type A emergency departments to the five newly-created
Emergency Department Visit APCs, 0609, 0613, 0614, 0615, and 0616.
We believed that our distinction between Type A and Type B
emergency departments refined and clarified the CPT definition of
``emergency department'' for use in the hospital context. As we have
previously noted, the CPT codes are defined to reflect the activities
of physicians, and do not always fully describe the range and mix of
services provided by hospitals during visits of emergency department
patients. For example, one feature that distinguishes Type A hospital
emergency departments from other departments of the hospital is that
Type
[[Page 66798]]
A emergency departments do not generally provide scheduled care, but
rather regularly operate to provide immediately available unscheduled
services.
We were pleased that the majority of commenters to the CY 2007
OPPS/ASC proposed rule agreed with our general distinction between Type
A and Type B emergency departments. We noted that after the publication
of the CY 2007 OPPS/ASC final rule with comment period, numerous
readers requested clarification about one paragraph that appeared in
that final rule. The paragraph is reprinted below (71 FR 68132).
``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 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.''
In response to the questions we received, in CY 2007 we posted on
the CMS Web site a ``Frequently Asked Questions'' list that described
various examples of treating an emergency department as either a Type A
emergency department or a Type B emergency department. In each case,
the posted answer stated that hospitals should contact their fiscal
intermediary to ensure that the fiscal intermediary and the hospital
are in agreement regarding the emergency room status as either Type A
or Type B. The response to the posted examples has been positive, and
the number of inquiries we are receiving has subsided.
Notwithstanding our subsequent clarification, we did not propose to
modify the definitions of Type A or Type B emergency departments for CY
2008 because we believed that our current definition accurately
distinguished between these two types of emergency departments. While
we would not know definitively until CY 2009 how the costs of services
provided in Type A emergency departments differed from the costs of
services provided in Type B emergency departments, we believed that our
current distinction between Type A and Type B emergency departments was
appropriate, and was most likely to capture any resource cost
differences between the two types of emergency departments. However, we
specifically solicited public comment regarding any additional
operational clarifications that we could provide to assist hospitals in
determining whether an emergency department is considered to be Type A
or Type B.
We specifically indicated for CY 2007 that hospitals should
individually consider separately identifiable areas or parts of
facilities that did not operate on the same schedule as the main
emergency department that was open 24 hours a day, 7 days per week to
determine the appropriate codes for reporting services provided in
those separately identifiable areas. Because we considered the main
distinguishing feature between Type A and Type B emergency departments
to be the full-time versus part-time availability of staffed areas for
emergency medical care, not the process of care or the site of care (on
the hospital's main campus or offsite), our final CY 2007 policy
explained that hospitals needed to assess separately identifiable areas
individually for their status as Type A or Type B emergency
departments. In the CY 2008 OPPS/ASC proposed rule, we specifically
solicited comments that described how this policy could be further
clarified in light of hospitals' operational responsibility to
efficiently provide emergency services, holding constant the
definitions that were developed for CY 2007 and described above. We did
not believe a policy change in the reporting of these Type A and Type B
emergency department codes would be appropriate for CY 2008, in light
of our desire to capture consistent and accurate hospital cost data by
HCPCS code for consideration for the CY 2009 OPPS. For CY 2008, we
proposed that Type A emergency department visits would continue to be
paid based on the five Emergency Department Visit APCs, while Type B
emergency department visits would continue to be paid based on the five
Clinic Visit APCs.
Comment: Many commenters requested that CMS adjust the policy to
broaden the definition of Type A emergency departments, specifically to
revise the rule that hospitals must carve out portions of the emergency
department that are not available 24 hours a day. The commenters
specifically requested that the definition be adjusted so that a ``fast
track'' area of an emergency department, located within the same
building as a Type A emergency department, would be considered Type A,
regardless of its hours of operation, if it provides unscheduled
emergency services and shares a common patient registration system with
the Type A emergency department. Many of the commenters expressed
concern that hospitals are currently overcrowded, and payment at clinic
visit rates may cause hospitals to shut down their ``fast track'' or
other areas of the hospital that deliver expedited care, yet are open
less than 24 hours a day. The commenters noted that if these areas of
the hospital were closed, emergency department overcrowding would be
exacerbated. Other commenters requested that we allow hospitals to
operate in the most efficient manner and not penalize them for creating
efficiencies. Several commenters requested additional clarification
regarding the difference between Type A and Type B emergency
departments, but did not specifically describe which part of the policy
was unclear. Several commenters noted that five payment levels for
emergency department visits was appropriate and would continue to
support a stable distribution of visit levels.
Response: As noted above, we consider the main distinguishing
feature between Type A and Type B emergency departments to be the full-
time versus part-time availability of staffed areas for emergency
medical care, not the process of care or the site of care (on the
hospital's main campus or offsite). We continue to believe that
emergency
[[Page 66799]]
departments or areas of the emergency department that are available
less than 24 hours a day may have lower resource costs than emergency
departments or areas of the emergency department that are available 24
hours a day. We do not believe a policy change in the reporting of
these Type A and Type B emergency department codes would be appropriate
for CY 2008, in light of our desire to capture consistent and accurate
hospital cost data by HCPCS code for consideration for the CY 2009
OPPS. In addition, if our Type A emergency department payments provide
support for 24 hour a day availability of services, then services
provided in areas of the hospital that are not staffed 24 hours a day
could be overpaid. This could also have the effect of diluting, and
ultimately decreasing, the median resource costs associated with Type A
emergency departments. We encourage hospitals that need more specific
information related to the distinction between Type A and Type B
emergency departments to contact their local fiscal intermediaries.
In response to several questions, we are slightly modifying the
long descriptors of HCPCS codes G0380, G0381, G0382, G0383, and G0384
by replacing the words ``this section'' with ``42 CFR Sec. 489.24'' in
order to clarify the reference. The short descriptors remain unchanged
for CY 2008. Table 44 lists the CY 2008 short and long descriptors for
the Type B emergency department Visit HCPCS codes.
Table 44.--CY 2008 Final Level II 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 visit... Level 1 hospital emergency 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 42 CFR
Sec. 489.24 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 visit... Level 2 hospital emergency 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 42 CFR
Sec. 489.24 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 visit... Level 3 hospital emergency 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 42 CFR
Sec. 489.24 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).
G0383..................... Lev 4 hosp type B ED visit... Level 4 hospital emergency 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 42 CFR
Sec. 489.24 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 5 hosp type B ED visit... Level 5 hospital emergency 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 42 CFR
Sec. 489.24 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).
----------------------------------------------------------------------------------------------------------------
In summary, we did not receive any public comments that described
how the payment policy could be further clarified in light of
hospitals' operational responsibility to efficiently provide emergency
services, holding constant the definitions that were developed for CY
2007. Therefore, we are finalizing our CY 2008 proposal, without
modification, to pay for Type A emergency department visits at the five
Emergency Department Visit APC rates, while Type B emergency department
visits will continue to be paid based on the five Clinic Visit APCs. We
are also slightly modifying the long descriptors of HCPCS codes G0380
through G0384 for clarification.
[[Page 66800]]
C. Visit Reporting Guidelines
1. Background
As described in section IX.A. of this final rule with comment
period, since April 7, 2000, we have instructed hospitals to report
facility resources for clinic and emergency department hospital
outpatient visits using the CPT E/M codes and to develop internal
hospital guidelines for reporting the appropriate visit level.
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 (67 FR 52133), 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, with the goal of ultimately applying national guidelines to
these codes and discontinuing the use of CPT E/M codes under the OPPS.
We also solicited public comments regarding national guidelines for
hospital coding of emergency department and clinic visits. We discussed
different 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. In that
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 response to comments, in the November 1, 2002 OPPS final rule
(67 FR 66793), we stated that we would not create new codes to replace
existing CPT E/M codes for reporting hospital visits until national
guidelines are developed. 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. We explained that organizations
such as the American Hospital Association (AHA) and the American Health
Information Management Association (AHIMA) had such expertise and would
be capable of creating hospital visit guidelines and providing ongoing
provider education. 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 reported for each type of hospital outpatient
visit (clinic or emergency department) 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. However, 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 OPPS 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, in CY
2003 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
other hospitals and associations on the AHA/AHIMA guidelines, clinical
review, and changing payment policies under 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 for 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 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 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 department 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 to 70 percent of the time. In addition, the vast
majority of the clinic and emergency department visits
[[Page 66801]]
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 believed 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 was 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 hospital reporting of visits using CPT E/M
codes that were assigned according to each hospital's internal
guidelines and the distribution of codes under the AHA/AHIMA
guidelines, nor were we able to demonstrate a normal distribution of
visit levels under the modified AHA/AHIMA guidelines. In CY 2007, we
posted to the CMS Web site a summary of the contractor's report.
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 stated in the CY 2007 OPPS/ASC final rule
with comment period (71 FR 68141) that we believed that the AHA/AHIMA
guidelines were the most appropriate and well-developed guidelines for
use in the OPPS of which we were aware. Our particular interest in
these guidelines was based upon the broad-based input into their
development, the desire for CMS to move to promulgate national hospital
outpatient visit coding guidelines in the near future, and full
consideration of the characteristics of alternative types of
guidelines. We also believed that hospitals would 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 noted that
we had been told that a number of hospitals were successfully utilizing
the AHA/AHIMA guidelines to report levels of hospital visits. However,
other organizations had expressed concern that the AHA/AHIMA guidelines
might 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, remained 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. As we
explained in the CY 2008 OPPS/ASC proposed rule (72 FR 42761), we
recognized that there could 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.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42761), we noted that
there were several types of concerns with the AHA/AHIMA guidelines that
had been identified based upon extensive staff review and contractor
use of the guidelines during the validation study. We believed that the
AHA/AHIMA guidelines would require refinement prior to their adoption
by the OPPS, as well as continued refinement over time after their
implementation. Our modified version of the AHA/AHIMA guidelines
provided some possibilities for addressing certain issues. We reviewed
our eight general areas of concern regarding the AHA/AHIMA model as
outlined below. In addition, we posted on the CMS Web site both the
original AHA/AHIMA guidelines and our modified draft version.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42761), we reiterated
our commitment to provide a minimum of 6 to 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. CY 2007 Work on Visit Guidelines
There were several areas of the AHA/AHIMA guidelines that we
identified in the CY 2007 OPPS/ASC final rule with comment period that
would require refinement and further input from the public prior to
implementation as national guidelines. These areas include the need for
five rather than three levels of codes for clinic and emergency
department visits to accommodate the CY 2007 five levels of OPPS
payment; clarification of documentation that would support certain
interventions; reconsideration of the inclusion of separately payable
services as proxies for hospital resources used in visits; examination
of the valuing of certain interventions; assessment of the need for
modifications to address the different clinical characteristics of
specialty clinic visits; consistency with the Americans with
Disabilities Act; re-evaluation of the way in which additional hospital
resources required for the treatment of new patients were captured; and
recommendations for guidelines for the reporting of visits to Type B
emergency departments.
In CY 2007, we had a number of meetings and discussions with
interested stakeholders regarding the AHA/AHIMA guidelines, the CMS
modified draft version, the contractor pilot work to test the
guidelines, the concerns we identified in the CY 2007 OPPS/ASC final
rule with comment period, and alternative guidelines. In the CY 2008
OPPS/ASC proposed rule (72 FR 42761), we indicated our awareness that
the AHA and AHIMA were conducting an ongoing dialogue with members of
their Hospital Evaluation and Management Coding Panel and reviewing
their previously recommended model guidelines as well as other models
currently in use. We had not received any additional suggestions or
modifications from the AHA and AHIMA at the time of the development of
the CY 2008 proposed rule. We had received a number of new suggestions
for guidelines from other stakeholders, including individual hospitals
and associations, that had engaged in a variety of data collection and
pilot application activities in preparing their recommendations. For
example, one wound care organization created and presented an
independent model that could apply to certain specialty clinics. The
organization claimed that several hospital outpatient specialty clinics
had already successfully implemented these as their internal
guidelines, but requested that CMS designate them as the national wound
care clinic guidelines. One provider group tested several sets of
guidelines that resembled the ACEP model and compared the results
across a set of hospitals. This provider group believed that an ACEP-
type model would be the most successful type of national guidelines,
assuming that the guidelines were flexible in serving as a guide to
visit level reporting. While using several varieties of ACEP-type
guidelines in different hospitals, the group noted that across
hospitals a specific intervention was almost always
[[Page 66802]]
assigned to the same clinic visit level. The group concluded that this
demonstrated that the ACEP model and its variations could likely be
successfully implemented as national guidelines. Another association
reviewed and tested the CMS modified AHA/AHIMA guidelines that were
posted on the CMS Web site. This association found it cumbersome to
assign the Level 2 and Level 4 clinic visit codes because those levels
could only be assigned when a certain number of interventions and/or
contributory factors were performed. The association suggested changes
to the CMS modified AHA/AHIMA guidelines for ease of use and
application to specialty clinics, particularly oncology clinics. One
developer of national clinic and emergency department visit guidelines
noted that many hospitals had successfully used the presenting problem-
based guidelines that it had created. The developer noted that its
system was easy to use, produced consistent coding decisions resulting
in a normal distribution of visits, and even served as a tool to track
effectiveness and efficiency.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42761), we expressed
our appreciation of the thoughtful information that had been provided
to us up to that time regarding hospitals' experiences and the
insightful responses by the public to our concerns about the AHA/AHIMA
model. We reiterated that we were actively engaged in evaluating and
comparing various guideline models and suggestions that had been
provided to us, and that we continued to welcome additional public
input on this important and complex area of the OPPS. The public input
we had received continued to reflect a wide variety of perspectives on
the types and content of the guidelines different commenters
recommended that we should implement nationally for the OPPS, and no
single approach appeared to be broadly endorsed by the stakeholder
community. In addition, we explained that commenters had described the
successful application of many types of internal hospital guidelines
with diverse characteristics for the reporting of hospital clinic and
emergency department visit levels that they believed accurately
captured the required hospital resources.
3. Visit Guidelines
In preparation for the CY 2008 OPPS/ASC proposed rule, we performed
data analyses with the goal of studying the current and historical
distribution of each level of clinic and emergency department visit
codes billed nationally, as well as the distribution among various
classes of hospitals. We analyzed frequency data from claims with dates
of service from March 1, 2002 through December 31, 2006, including
those claims that were processed through December 31, 2006. To
determine the national clinic visit distribution, we reviewed frequency
data for each level of new patient visits, established patient visits,
and consultation codes. To determine the national emergency department
visit distribution, we reviewed frequency data for the five CPT
emergency department visit codes. We did not include the five G-codes
that describe Type B emergency departments because they became
effective January 1, 2007, and we do not yet have a full year of
frequency data for those codes.
The clinic visit data, displayed below in Figure 1 that is
reprinted from the CY 2008 OPPS/ASC proposed rule, revealed a fairly
normal national distribution of clinic visits, with the curve somewhat
skewed to the left, consistent with our previous analysis of these data
in CY 2002 (67 FR 66791). In addition, we noted that the visit
distributions had been quite stable over the past 5 years.
Figure 1.--Frequency Distribution of New and Established Patient Clinic
Visits, by Level of Code
[[Page 66803]]
[GRAPHIC] [TIFF OMITTED] TR27NO07.002
The graph shown in Figure 1 indicated that hospitals, on average,
were billing all five levels of visit codes with varying frequency, in
a consistent pattern over time. It was striking to note how similar the
annual distributions appeared from CY 2002 through CY 2006. We were not
surprised that hospitals reported a relatively high proportion of low-
level visits, given the typical clinical care provided in HOPDs during
these visits. Many Medicare patients are evaluated regularly in clinics
by hospitals' clinical staff to determine the status of their chronic
medical conditions and to make adjustments to treatment plans, and
those visits may frequently be reported as a low-level visit if that is
consistent with the hospital's internal guidelines and fiscal
intermediary instructions. Some patients may receive minor services
during low-level visits that are not described by more specific HCPCS
codes. We noted that, in general, billing a visit in addition to
another service merely because the patient interacted with hospital
staff or spent time in a room for that service would be inappropriate.
If a visit and another service were both billed, such as chemotherapy,
a diagnostic test, or a surgical procedure, the visit should be
separately identifiable from the other service because the resources
used to provide nonvisit services, including staff time, equipment, and
supplies, among others, were captured in the line item for that
service. We believed that hospitals by and large were abiding by this
guidance because more than 90 percent of the CY 2006 claims for Level 1
established patient visits available for the CY 2008 OPPS/ASC proposed
rule were single claims.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42761), we also
examined the billing patterns for various classes of hospitals, grouped
by the hospital categories shown in the impact table (Table 61) in
section XXIV.B. of this final rule with comment period, to see how the
clinic visit distributions of levels reported for these various
categories compared to the national distribution of clinic visit
levels. For these subcategories, we specifically focused on the number
of established patient visits billed at each level. Generally, the
distribution for major teaching hospitals, minor teaching hospitals,
and nonteaching hospitals looked remarkably similar to the
[[Page 66804]]
national distribution of established patient visits. Nonteaching
hospitals tended to bill a greater proportion of Level 1 and 2 patient
visits as compared to major teaching hospitals, as would be expected if
their general patient acuity was slightly lower. Nonteaching hospitals
include many community hospitals that treat a wide variety of patients,
likely including a larger proportion of patients with minor ailments.
Major teaching hospitals reported a slightly higher proportion of Level
4 and 5 visits. This too correlated positively with our knowledge of
the patient case-mix of large teaching hospitals, which tend to treat a
higher proportion of very sick patients than nonteaching hospitals. The
distributions for urban and rural hospitals also closely resembled the
national distribution, including the rural SCH visit level
distribution. The smallest rural hospitals predictably reported a
higher proportion of Level 1 and 2 visit codes and a lower proportion
of higher level visit codes, as compared to the national average,
consistent with their generally lower case-mix severity.
The national emergency department visit data, displayed below in
Figure 2 that is reprinted from the CY 2008 OPPS/ASC proposed rule,
similarly revealed a normal national distribution of emergency
department visit levels that was even more symmetrical than the
national clinic visit distribution. The national distributions were
stable over the past 5 years as well.
Figure 2.--Frequency Distribution of Emergency Department Visits, by
Level of Code
[GRAPHIC] [TIFF OMITTED] TR27NO07.003
In the CY 2008 OPPS/ASC proposed rule (72 FR 42761), we also looked
at various classes of hospitals, grouped by the hospital categories
that we show in the impact table in section XXIV.B. of this final rule
with comment period, to see how the emergency department visit
distributions of levels billed by hospitals in each of these various
categories compared to the national distribution of emergency
department visit levels. The emergency department visit distributions
for major teaching hospitals, minor teaching hospitals, and nonteaching
hospitals were almost identical to the national distribution of
emergency department visits. No significant differences were noted. The
[[Page 66805]]
emergency department visit distributions for urban and rural hospitals
also closely resembled the national distribution of emergency
department visits. Rural hospitals in the aggregate reported slightly
higher proportions of Level 2 and 3 emergency department visits than
the national average, and slightly fewer Level 4 and 5 visits. When
subdividing rural hospitals into groupings based on size, the
distribution for small, medium, and large rural hospitals closely
mirrored the national average distribution. Large rural hospitals
tended to report higher level emergency department visits than smaller
rural hospitals. All of these observations regarding the patterns of
reporting for rural hospitals were consistent with our expectations for
care delivery at those hospitals.
Overall, both the clinic and emergency department visit
distributions indicated that hospitals were billing consistently over
time and in a manner that distinguished between visit levels, resulting
in relatively normal distributions nationally for the OPPS, as well as
for smaller classes of hospitals. These proposed rule analyses were
generally consistent with our understanding of the clinical and
resource characteristics of different levels of hospital outpatient
clinic and emergency department visits.
In the CY 2008 OPPS/ASC proposed rule, we specifically invited
public comment as to whether a pressing need for national guidelines
continued at this point in the maturation of the OPPS, or if the
current system where hospitals create and apply their own internal
guidelines to report visits was currently more practical and
appropriately flexible for hospitals. We explained that although we
have reiterated our goal since CY 2000 to create national guidelines,
this complex undertaking for these important and common hospital
services was proving more challenging than we initially thought as we
received new and expanded information from the public on current
hospital reporting practices that led to appropriate payment for the
hospital resources associated with clinic and emergency department
visits. We believed that many hospitals had worked diligently and
carefully to develop and implement their own internal guidelines that
reflected the scope and types of services they provided throughout the
hospital outpatient system. Based on public comments, as well as our
own knowledge of how clinics operate, it seemed unlikely that one set
of straightforward national guidelines could apply to the reporting of
visits in all hospitals and specialty clinics. In addition, the stable
distribution of clinic and emergency department visits reported under
the OPPS over the past several years indicated that hospitals, both
nationally in the aggregate and grouped by specific hospital classes,
were generally billing in an appropriate and consistent manner as we
would expect in a system that accurately distinguished among different
levels of service based on the associated hospital resources.
Therefore, while we explained in the CY 2008 OPPS/ASC proposed rule
that we would continue to evaluate the information and input we had
received from the public during CY 2007, as well as comments on the CY
2008 OPPS/ASC proposed rule, regarding the necessity and feasibility of
implementing different types of national guidelines, we did not propose
to implement national visit guidelines for clinic or emergency
department visits for CY 2008. Instead, hospitals would continue to
report visits during CY 2008 according to their own internal hospital
guidelines.
In the absence of national guidelines, we will continue to
regularly reevaluate patterns of hospital outpatient visit reporting at
varying levels of disaggregation below the national level to ensure
that hospitals continued to bill appropriately and differentially for
these services. In addition, we note our expectation that hospitals'
internal guidelines would comport with the principles listed below.
(1) The coding guidelines should follow the intent of the CPT code
descriptor in that the guidelines should be designed to reasonably
relate the intensity of hospital resources to the different levels of
effort represented by the code (65 FR 18451).
(2) The coding guidelines should be based on hospital facility
resources. The guidelines should not be based on physician resources
(67 FR 66792).
(3) The coding guidelines should be clear to facilitate accurate
payments and be usable for compliance purposes and audits (67 FR
66792).
(4) The coding guidelines should meet the HIPAA requirements (67 FR
66792).
(5) The coding guidelines should only require documentation that is
clinically necessary for patient care (67 FR 66792).
(6) The coding guidelines should not facilitate upcoding or gaming
(67 FR 66792).
We also proposed the following five additional principles for
application to hospital-specific guidelines, based on our evolving
understanding of the important issues addressed by many hospitals in
developing their internal guidelines that now have been used for a
number of years. We believed that it was reasonable to elaborate upon
the standards for hospitals' internal guidelines that we proposed to
apply in CY 2008, based on our knowledge of hospitals' experiences to
date with guidelines for visits.
(7) The coding guidelines should be written or recorded, well-
documented, and provide the basis for selection of a specific code.
(8) The coding guidelines should be applied consistently across
patients in the clinic or emergency department to which they apply.
(9) The coding guidelines should not change with great frequency.
(10) The coding guidelines should be readily available for fiscal
intermediary (or, if applicable, MAC) review.
(11) The coding guidelines should result in coding decisions that
could be verified by other hospital staff, as well as outside sources.
In the CY 2008 OPPS/ASC proposed rule, we invited public comment on
these principles, specifically, whether hospitals' guidelines currently
met these principles, how difficult it would be for hospitals'
guidelines to meet these principles if they did not meet them already,
and whether hospitals believed that certain standards should be added
or removed. We considered stating that a hospital must use one set of
emergency department visit guidelines for all emergency departments in
the hospital but thought that some departments that might be considered
emergency departments, such as the obstetrics department, might find it
more practical and appropriate to use a different set of guidelines
than the general emergency department. Similarly, we believed that it
was possible that various specialty clinics in a hospital could have
their own set of guidelines, specific to the services offered in those
specialty clinics. However, if different guidelines were implemented
for different clinics, we stated that hospitals should ensure that
these guidelines reflected comparable resource use at each level to the
other clinic guidelines that the hospital might apply.
Comment: A number of commenters were divided as to whether there is
a need for national guidelines. The majority of the commenters
requested that CMS continue work on national guidelines to ensure
consistent reporting of hospital visits. Some of the commenters
requested that the guidelines be implemented as soon as possible,
ensuring 6 to 12 months of advance notice. Other commenters suggested
that guidelines would be helpful, but that it was preferable to invest
significant time reviewing and
[[Page 66806]]
perfecting guidelines rather than to quickly implement guidelines that
could later prove to be problematic. Several commenters requested that
CMS create national guidelines and then request the development of CPT
codes specific to hospital visits. Several commenters offered their
assistance in creating specialty clinic guidelines, reviewing
guidelines, or helping in other ways, with the ultimate goal of
creating national guidelines. One commenter believed it is absolutely
necessary to create national guidelines, particularly because CMS is
moving toward greater packaging.
Other commenters stated that the principles that were included in
the CY 2008 OPPS/ASC proposed rule were appropriate, reasonable, and
sufficient, and that it was unnecessary to implement national
guidelines. The commenters stated that hospital specific guidelines are
practical and appropriately flexible. Several of the commenters noted
that their own internal guidelines already met all of the principles,
or that the internal guidelines used by member hospitals or their
associations likely already comply with these principles. Other
commenters requested that the AMA include these principles in the CPT
book to clarify that the CPT E/M code descriptors do not fully describe
hospital resources, and that it is appropriate for hospitals to use
their internal guidelines to code hospital outpatient visits.
Several commenters asked for clarification of details related to
the principles, such as how often the guidelines should be updated, how
``readily available'' is defined, and whether hospitals can use
physician guidelines to report hospital visits. Some commenters
believed the principles were too vague and strongly encouraged the
creation of national guidelines. Several commenters requested that CMS
inform the fiscal intermediaries and MACs that they should use each
hospital's internal guidelines as a reference when auditing hospital
records, rather than using only the fiscal intermediary's own set of
guidelines. One commenter requested clarification related to how a
hospital could create several sets of guidelines for various areas of
the hospital. Many commenters requested clarification about whether
separately payable services could be included in internal guidelines,
in the absence of national guidelines.
Response: We appreciate all the thoughtful comments that we
received related to the creation of national guidelines, as well as
offers from hospitals and associations to help create guidelines. We
acknowledge that it would be desirable to many hospitals to have one
set of national guidelines. However, we also understand that it would
be disruptive to other hospitals that have successfully adopted
internal guidelines to implement any new set of national guidelines,
while we address the problems that would be inevitable in the case of
any new set of guidelines that would be applied by thousands of
hospitals. Creating national guidelines has proven more difficult than
initially anticipated, as detailed above, and some hospitals have
expressed significant concerns about virtually all of the models we
have discussed.
Based on our analyses for the CY 2008 proposed rule, both clinic
and emergency department national visit distributions appear normal and
relatively stable over time, indicating that hospitals as a whole are
billing the full range of visit codes in an appropriate manner, a
reassuring finding. We noted similar distributions for subclasses of
hospitals, as well. We will continue to work on national guidelines,
and we continue to encourage comments and submission of successful
models. In the meantime, before national guidelines are implemented, we
will require each hospital's internal guidelines to meet the principles
stated above. We agree with commenters that it could be useful for the
AMA to publish these principles in order to clarify that it is
appropriate for hospitals to apply different guidelines than
physicians' guidelines to report visits provided in HOPDs. We encourage
interested parties to contact the AMA to determine whether there is an
appropriate forum to publish these principles, so that they are broadly
distributed and readily available.
We will elaborate on the principles that were commented on by
several commenters. The second principle states that the guidelines
should not be based on physician resources. Hospitals are responsible
for reporting the CPT E/M visit code that appropriately represents the
resources utilized by the hospital, rather than the resources utilized
by the physician. This does not preclude a hospital from using or
adapting the physician guidelines if the hospital believes that such
guidelines adequately describe hospital resources. We note that the
first principle states that coding guidelines should follow the intent
of the CPT code descriptor to relate the intensity of resources to
different levels of effort represented by the code, not that the
hospital's guidelines need to specifically consider the three factors
included in the CPT E/M codes for consideration regarding physician
visit reporting.
Regarding principle 8, a hospital with multiple clinics (for
example, primary care, oncology, wound care, etc.) may have different
coding guidelines for each clinic, but the guidelines must be applied
uniformly within each separate clinic. We note that the hospital's
assorted set of internal guidelines must measure resource use in a
relative manner, in relation to each other. For example, the hospital
resources required for a Level 3 established patient visit under one
set of guidelines should be comparable to the resources required for a
Level 3 established patient visit under all other sets of clinic visit
guidelines used by the hospital.
Regarding principle 9, we would generally expect hospitals to
adjust their guidelines less frequently than every few months, and we
believe it would be reasonable for hospitals to adjust their guidelines
annually, if necessary.
Regarding principle 10, hospitals should use their judgment to
ensure that coding guidelines are readily available, in an appropriate
and reasonable format. We would encourage fiscal intermediaries and
MACs to review a hospital's internal guidelines when an audit occurs.
Regarding principle 11, hospitals should use their judgment to
ensure that their coding guidelines can produce results that are
reproducible by others.
In the absence of national visit guidelines, hospitals have the
flexibility to determine whether or not to include separately payable
services as a proxy to measure hospital resource use that is not
associated with those separately payable services. The costs of
hospital resource use associated with those separately payable services
would be paid through separate OPPS payment for the other services. We
encourage hospitals with more specific questions related to the
creation of internal guidelines to contact their local fiscal
intermediary or MAC.
Comment: Many commenters requested that CMS allow hospitals to bill
critical care without a minimum time requirement or with a time
requirement of 15 minutes. The commenters noted that the hospital may
have its greatest resource use in the first 10 minutes of critical
care, much earlier than the 30-minute minimum required in the code
descriptor.
Response: The CPT instructions for reporting of critical care
services with CPT code 99291 (Critical care, evaluation and management
of the critically ill or critically injured patient; first 30-74
minutes) and the CPT code descriptor specify that the code can only
[[Page 66807]]
be billed if 30 minutes or more of critical care services are provided.
Because hospitals will be reporting CPT codes for critical care
services for CY 2008, they must continue to provide a minimum of 30
minutes of critical care services in order to bill CPT code 99291,
according to the CPT code descriptor and CPT instructions. We note that
hospitals can report the appropriate clinic or emergency department
visit code consistent with their internal guidelines if fewer than 30
minutes of critical care is provided.
We appreciate all of the comments we have received in the past from
the public on visit guidelines, and we encourage at any time continued
submission of comments that will assist us and other stakeholders
interested in the development of national guidelines. Until national
guidelines are established, hospitals should continue using their own
internal guidelines to determine the appropriate reporting of different
levels of clinic and emergency department visits. We would not expect
individual hospitals to necessarily experience a normal distribution of
visit levels across their claims, although we would expect a normal
distribution across all hospitals as currently observed and as we would
also expect if national guidelines were implemented. We understand
that, based on different patterns of care, we could expect that a small
community hospital might provide a greater percentage of low-level
services than high-level services, while an academic medical center or
trauma center might provide a greater percentage of high-level services
than low-level services. We would also expect national guidelines to
provide for five levels of coding, to parallel the five payment levels
that currently exist.
In addition, we are adopting our CY 2008 proposal, without
modification, that all hospital-specific guidelines for reporting
visits should meet the 11 guideline principles listed earlier in this
final rule with comment period.
While we understand the interest of some hospitals in our moving
quickly to promulgate national guidelines that will ensure standardized
reporting of hospital outpatient visit levels, we believe that the
issues and concerns identified both by us 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 to 12 months notice prior to implementation of national
guidelines, we would not implement national guidelines prior to CY
2009. Our goal is to ensure that OPPS national or hospital-specific
visit guidelines continue to facilitate consistent and accurate
reporting of hospital outpatient 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.
X. OPPS 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 Program Transmittal 496
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 the 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 special 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
[[Page 66808]]
and by presenters at the September 2004 APC Panel meeting, without
putting beneficiary access to these low volume blood products at risk.
We have adopted the use of this modified CCR process for calculating
unadjusted median costs for blood and blood products each year since
the CY 2005 OPPS.
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 (70 FR 68687).
In the CY 2007 OPPS, we established 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. However, we provided 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 was greater than 25
percent. Specifically, we set 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 was based.
B. Payment for Blood and Blood Products
In the CY 2008 OPPS/ASC proposed rule (72 FR 42766 through 42767),
we proposed to set the payment rates for blood and blood products for
CY 2008 at the unadjusted median cost for these products, calculated
using the hospital-specific simulated blood CCR for each hospital that
does not have a blood cost center. For the proposed rule, we calculated
median costs for blood and blood products using claims for services
furnished on or after January 1, 2006, and before January 1, 2007,
using the actual or simulated CCRs from the most recently available
hospital cost reports. The median costs derived from this data process
were relatively stable compared to the median costs on which payment is
based for CY 2007. Of the 34 blood and blood products, the proposed
median costs increased for 24 products and declined for 10 products
compared to the adjusted medians on which payment is based in CY 2007.
Products with the largest proposed declines were, like the products
with the greatest increases, mostly those products with low volume use
in the hospital outpatient setting. The products whose proposed costs
declined more than 5 percent account for less than 1 percent of the
total volume of blood and blood products in the claims used to
calculate the proposed rates. No product's median cost declined by more
than 18 percent in the proposed rule data. The products whose proposed
median costs increased account for 79 percent of the total volume of
blood and blood products in the claims used to calculate the proposed
rates.
As we indicated in the CY 2007 OPPS/ASC final rule with comment
period (71 FR 68147), we believe that the simulated CCR methodology
results in accurate reflections of the relative estimated costs of
these products for hospitals without blood cost centers and, therefore,
for these products in general. Our 1-year adjustment to the median
costs for CY 2007, where the median costs for blood and blood products
decreased by more than 25 percent from the CY 2006 adjusted median
costs, was intended to provide a reasonable transition to use of the
simulated median costs for payment of blood and blood products under
the OPPS without further adjustment. The medians that result from the
use of the simulated CCR process and the CY 2006 claims available for
the proposed rule generally result in median costs that we believe
provide an appropriate basis for the relative weights on which the CY
2008 payments for blood and blood products would be based. Therefore,
we proposed to use the median costs derived from the application of
blood cost center CCRs for those hospitals that have blood cost centers
or simulated blood cost center CCRs for those hospitals that do not
have blood cost centers as the basis for the CY 2008 payments for blood
and blood products, without further adjustment.
We received several public comments regarding this proposal. A
summary of the comments and our responses follows.
Comment: Some commenters supported CMS' proposal to increase the
APC payment rates for many blood products. One commenter expressed
support for our methodology of utilizing hospital-specific actual or
simulated CCRs for blood cost centers to convert hospital charges for
blood and blood products to costs, noting that this methodology is
consistent with the principles of a prospective payment system.
Other commenters, however, stated that the payment rates for many
blood and blood products do not adequately reflect their acquisition,
management, and processing costs. They noted that the costs of blood
and blood products continue to increase due to safety requirements,
technological advances, and donor recruitment and retention challenges,
and that the 2-year lag inherent in OPPS ratesetting would not allow
these costs to be captured.
In particular, these commenters were concerned that the median unit
cost published in the proposed rule for the blood product with the
highest Medicare volume, leukocyte-reduced red blood cells, is less
than the acquisition cost of the product and would fail to pay
hospitals for overhead costs (for example, storage, handling, inventory
management). One commenter referred to data submitted by 1,600
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). According
to the AABB survey, the proposed CY 2008 payment for leukocyte reduced
red blood cells is less than what hospitals paid for this product in
2004.
Response: The median costs for blood and blood products in this
final rule with comment period are derived from the CY 2006 hospital
outpatient claims data and have the benefit of reflecting the reporting
clarifications 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. CY 2006
claims are the first OPPS claims that represent a full year of
hospitals' reporting consistent with our detailed blood billing
guidelines issued in CY 2005. Thus, we expect that the reporting of
charges and units for blood and blood products in CY 2006 has improved
over past years, especially with respect to hospitals' inclusion of all
charges related to acquisition, processing, and handling of blood and
blood products as specifically described in each of the relevant HCPCS
P-code descriptors. As such, we believe that the median costs for blood
and blood products from the CY 2006 claims data reflect this improved
reporting of charges and units for these products, particularly with
[[Page 66809]]
regard to the most commonly furnished blood and blood products, such as
leukocyte-reduced red blood cells. We do not believe it is necessary or
appropriate to incorporate external data such as the AABB survey into
our ratesetting process for blood and blood products because in a
relative weight system, it is the relativity of costs to one another,
rather than absolute cost, that is most important. External data lack
relativity to the estimated costs derived from the claims and cost
report data and generally are not appropriate for determining relative
weights that result in payment rates.
Comment: One commenter noted that charges billed under revenue code
0391 are mapped to the blood bank cost center under cost reporting
rules and in the revenue code to cost center crosswalk that we use to
reduce charges to estimated costs. According to the commenter, blood
transfusion or blood administration services billed under this revenue
code represent charges for nursing costs to administer the blood
products, rather than blood bank costs for the products themselves. The
commenter stated that the CCR used by CMS to calculate median unit
costs for blood is lowered as a result of revenue code 0391 mapping to
the blood bank cost center, because charges associated with blood
administration are included in the divisor for the blood bank CCR.
Accordingly, the commenter requested that CMS not map charges billed
under 0391 to the blood bank cost center.
Response: Revenue code 0391 maps to cost report center 4700, Blood
Storing, Processing, and Transfusing. Because this cost center includes
transfusion services in its title, it is appropriate for hospitals to
report charges under revenue code 0391 for nursing costs to administer
blood products, as well as for blood storage and processing, and for
revenue code 0391 to map to this cost center. We do not agree that we
should change our revenue code to cost center crosswalk.
After consideration of the public comments received on this
proposal, we are finalizing, without modification, 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.
Table 45 below reflects the final median unit costs developed using
the methodology described above and compares the difference between the
CY 2008 simulated CCR median unit costs and the CY 2007 adjusted
simulated CCR median unit costs. Of the 34 blood products, median costs
per unit (calculated using the simulated blood-specific CCR
methodology) for CY 2008 rise for 19 of them compared to their CY 2007
adjusted simulated median unit costs. These 19 products account for
about 77 percent of all units of blood and blood products furnished to
Medicare beneficiaries in the HOPD as reflected in our CY 2006 claims
data. The median costs decline for 15 products, which constitute
approximately 23 percent of all units of blood and blood products
furnished to Medicare beneficiaries in the HOPD in CY 2006. Unlike in
previous years, none of the high-volume products experience decreases
of more than 25 percent. While it is true that more blood and blood
products experienced a decline compared to CY 2007 adjusted simulated
median costs using final rule data compared with proposed rule data,
these changes are relatively minor and consistent with normal
fluctuations due to CCR changes and inclusion of claims from additional
providers that are commonly observed for OPPS services when additional
data are considered for the final rule.
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, with medians increasing as much as 84 percent compared
to CY 2007 adjusted simulated median costs. Overall, of the 11 low-
volume products, 7 products show increases in their median unit costs
compared to their CY 2007 adjusted simulated median unit costs, and 4
products show decreases in their median unit costs compared to their CY
2007 adjusted simulated median unit costs. The 4 low-volume products
for which the median costs decline compared to their CY 2007 adjusted
simulated median unit costs represent only 0.18 percent of the total
units of blood products furnished in the CY 2006 OPPS claims data.
In summary, we are setting the final payment rates for blood and
blood products for CY 2008 based on the unadjusted medians for blood
and blood products (calculated using the simulated blood-specific CCR
methodology) that are derived from CY 2006 claims data as we have
described. We are reassured by the relatively stable or slightly
increasing median costs from CY 2005 to CY 2006 claims data for most
blood products, a pattern that we believe may reflect more accurate and
complete hospital reporting and charging practices for these products.
Consistent with our billing guidelines, hospitals may now be taking
into consideration all appropriate costs associated with providing
blood and blood products when charging for those products under the
OPPS. Unlike in previous years, we do not believe it is necessary to
provide a transitional payment adjustment. Under this final policy, we
expect that payments would increase for approximately 77 percent of
blood and blood product units if patterns of furnishing blood products
in CY 2008 remain similar to those in CY 2006.
Table 45.--CY 2008 Median Costs for Blood and Blood Products
----------------------------------------------------------------------------------------------------------------
CY 2007
Payment
median: Higher
of CY 2007
simulated CCR CY 2008
HCPCS code* Short descriptor CY 2008 units median unit simulated CCR
cost or 75% of median unit
CY 2006 cost
adjusted
median unit
cost
----------------------------------------------------------------------------------------------------------------
P9010.............................. Whole blood for transfusion 2,687 $131 $252
P9011.............................. Blood split unit........... 330 136 147
P9012.............................. Cryoprecipitate each unit.. 5,811 48 41
[[Page 66810]]
P9016.............................. RBC leukocytes reduced..... 624,120 175 183
P9017.............................. Plasma 1 donor frz w/in 8 47,159 70 66
hr.
P9019.............................. Platelets, each unit....... 21,160 59 69
P9020*............................. Plaelet rich plasma unit... 791 208 359
P9021.............................. Red blood cells unit....... 155,886 129 128
P9022.............................. Washed red blood cells unit 2,473 210 274
P9023*............................. Frozen plasma, pooled, sd.. 376 57 73
P9031.............................. Platelets leukocytes 18,608 95 106
reduced.
P9032.............................. Platelets, irradiated...... 10,940 129 120
P9033.............................. Platelets leukoreduced 4,970 125 138
irrad.
P9034.............................. Platelets, pheresis........ 9,858 450 436
P9035.............................. Platelet pheres 51,624 486 493
leukoreduced.
P9036.............................. Platelet pheresis 1,437 416 413
irradiated.
P9037.............................. Plate pheres leukoredu 26,026 614 622
irrad.
P9038.............................. RBC irradiated............. 6,091 196 193
P9039.............................. RBC deglycerolized......... 908 356 343
P9040.............................. RBC leukoreduced irradiated 79,642 216 237
P9043*............................. Plasma protein fract, 5%, 24 51 93
50ml.
P9044.............................. Cryoprecipitate reduced 5,437 82 83
plasma.
P9048*............................. Plasmaprotein fract, 5%, 624 237 213
250ml.
P9050*............................. Granulocytes, pheresis unit 13 746 1,371
P9051*............................. Blood, l/r, cmv-neg........ 3,831 156 146
P9052.............................. Platelets, hla-m, l/r, unit 1,723 668 638
P9053.............................. Plt, pher, l/r cmv-neg, irr 1,627 701 678
P9054.............................. Blood, l/r, froz/degly/wash 668 210 216
P9055*............................. Plt, aph/pher, l/r, cmv-neg 922 395 483
P9056.............................. Blood, l/r, irradiated..... 3,986 143 145
P9057.............................. RBC, frz/deg/wsh, l/r, 156 493 369
irrad.
P9058.............................. RBC, l/r, cmv-neg, irrad... 3,552 261 260
P9059.............................. Plasma, frz between 8- 3,480 74 77
24hour.
P9060.............................. Fr frz plasma donor 319 74 52
retested.
----------------------------------------------------------------------------------------------------------------
* Indicates CY 2007 payment at 75 percent of CY 2006 adjusted median cost.
XI. OPPS Payment for Observation Services
A. Observation Services (HCPCS code G0378)
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.
Payment for all observation care under the OPPS was packaged prior
to CY 2002. Since CY 2002, separate payment of a single unit of an
observation APC for an episode of observation care has been provided in
limited circumstances. Effective for services furnished on or after
April 1, 2002, separate payment for observation was made if the
beneficiary had chest pain, asthma, or congestive heart failure and met
additional criteria for diagnostic testing, minimum and maximum limits
to observation care time, physician care, and documentation in the
medical record (66 FR 59879). Payment for observation care that did not
meet these specified criteria was packaged. Between CY 2003 and CY
2006, several more changes were made to the OPPS policy regarding
separate payment for observation care, such as: clarification that
observation is not separately payable when billed with ``T'' status
procedures on the day of or day before observation care; development of
specific Level II HCPCS codes for hospital observation care and direct
admission to observation care; and removal of the initially established
diagnostic testing requirements for separately payable observation (67
FR 66794, 69 FR 65828, and 70 FR 68688). Throughout this time period,
we maintained separate payment for observation care only for the three
specified medical conditions, and OPPS payment for observation for all
other clinical conditions remained packaged.
Since January 1, 2006, hospitals have reported observation services
based on an hourly unit of care using HCPCS code G0378 (Hospital
observation services, per hour). This code has a status indicator of
``Q'' under the CY 2007 OPPS, meaning that the OPPS claims processing
logic determines whether the observation is packaged or separately
payable. The OCE's current logic determines whether observation
services billed under HCPCS code G0378 is separately payable through
APC 0339 (Observation), or whether payment for observation services
will be packaged into the payment for other separately payable services
provided by
[[Page 66811]]
the hospital in the same encounter based on criteria discussed below.
Also since January 1, 2006, hospitals have reported HCPCS code G0379
(Direct admission of patient for hospital observation care) for a
direct admission of a patient to observation care. The OPPS pays
separately for that direct admission reported under HCPCS code G0379 in
situations where payment for the actual observation services reported
under HCPCS G0378 are packaged and where the direct admission meets
certain other criteria. The OCE logic determines when HCPCS code G0379
is separately payable under the OPPS.
For CY 2007, we continued to apply the criteria for separate
payment for observation care and the coding and payment methodology for
observation care that were implemented in CY 2006. Observation care is
reported using HCPCS code G0378 and observation that meets the criteria
for separate payment maps to APC 0339 (Observation). The current
criteria for separate payment for observation (APC 0339) are:
A. Diagnosis Requirements
1. The beneficiary must have one of three medical conditions:
congestive heart failure (CHF), chest pain, or asthma.
2. Qualifying ICD-9-CM diagnosis codes must be reported in Form
Locator (FL) 76, Patient Reason for Visit, or FL 67, principal
diagnosis, or both in order for the hospital to receive separate
payment for APC 0339. If a qualifying ICD-9-CM diagnosis code(s) is
reported in the secondary diagnosis field, but is not reported in
either the Patient Reason for Visit field (FL 76) or in the principal
diagnosis field (FL 67), separate payment for APC 0339 is not allowed.
B. Observation Time
1. Observation time must be documented in the medical record.
2. A beneficiary's time in observation (and hospital billing)
begins with the beneficiary's admission to an observation bed.
3. A beneficiary's time in observation (and hospital billing) ends
when all clinical or medical interventions have been completed,
including followup care furnished by hospital staff and physicians that
may take place after a physician has ordered the patient to be released
or admitted as an inpatient.
4. The number of units reported with HCPCS code G0378 must equal or
exceed 8 hours.
C. Additional Hospital Services
1. The claim for observation services must include one of the
following services in addition to the reported observation services.
The additional services listed below must have a line item date of
service on the same day or the day before the date reported for
observation:
An emergency department visit (APC 0609, 0613, 0614, 0615,
or 0616); or
A clinic visit (APC 0604, 0605, 0606, 0607, or 0608); or
Critical care (APC 0617); or
Direct admission to observation reported with HCPCS code
G0379 (APC 0604).
2. No procedure with a ``T'' status indicator can be reported on
the same day or day before observation care is provided.
D. Physician Evaluation
1. The beneficiary must be in the care of a physician during the
period of observation, as documented in the medical record by
admission, discharge, and other appropriate progress notes that are
timed, written, and signed by the physician.
2. The medical record must include documentation that the physician
explicitly assessed patient risk to determine that the beneficiary
would benefit from observation care.
The CY 2007 list of diagnoses eligible as a criterion for separate
payment for observation services may be found in Table 44 of the CY
2007 OPPS/ASC final rule with comment period (71 FR 68152).
For CY 2007, we made one minor change in payment for direct
admission to observation. As part of the changes in APC assignments and
payments for clinic and emergency department visits, low level clinic
visits were moved from APC 0600 (Low Level Clinic Visits) to APC 0604
(Level 1 Clinic Visits), with a CY 2007 payment rate of approximately
$51. Under the circumstances where direct admission to observation is
separately payable, we finalized our CY 2007 assignment of HCPCS code
G0379 to APC 0604, consistent with its CY 2006 placement in the APC for
Low Level Clinic Visits.
During the APC Panel's August 2006 meeting, the Observation
Subcommittee made several recommendations regarding observation
services. The first recommendation was that CMS consider adding syncope
and dehydration to the list of 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 CMS to consider revising criteria for separately
payable observation care 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 care, and all other criteria for
separate observation payment (for example, qualifying diagnosis code,
number of hours) are met. The Panel also voted to change the name of
the Observation Subcommittee to the Observation and Visit Subcommittee,
based on the Panel's interest in expanding the scope of the
subcommittee's work.
In response to the August 2006 APC Panel recommendations and public
comments on the CY 2007 OPPS/ASC proposed rule, we stated in the CY
2007 OPPS/ASC final rule with comment period that we intended 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 care, as well as the
possibility of allowing separate observation payment for claims for
observation care that also included specific minor or routine
procedures that have ``T'' status indicators (71 FR 68150).
At the March 2007 APC Panel meeting, we discussed with the
Observation and Visit Subcommittee and the full Panel the results of
the requested data analyses regarding syncope and dehydration, as well
as the occurrences of claims for observation care that also include
specific minor or routine procedures that have ``T'' status indicators.
With respect to the diagnosis analyses, the data presented to the
Subcommittee and Panel (consisting of partial year 2006 claims data
that were less complete than the claims data available for the proposed
rule) showed that there were 136,977 claims for separately payable
observation services for the currently eligible conditions of chest
pain, asthma, and congestive heart failure, with a median cost of $453.
The frequency of claims for observation services for the diagnoses of
syncope and dehydration, when all other criteria for separate payment
of observation services (other than diagnosis) were met, was 46,961
claims, with a somewhat lower median cost of $416. The effect of adding
both syncope and dehydration to the current diagnoses eligible for
separate payment would be to lower the median cost for APC 0339
slightly to $443, based on the early partial 2006 data presented to the
Subcommittee and Panel. For the study of ``T'' status procedures in
relation to observation, we identified relatively few instances (5,162)
where observation met all of the criteria for separate payment,
[[Page 66812]]
including the current three conditions of CHF, asthma, chest pain,
except for the presence of a ``T'' status procedure. Of these claims,
very few had any significant frequency. The most common procedures were
those relating to heart catheterization, angioplasty procedures, and
endoscopies. As we have stated in the past, we believe that the
observation services in these cases may be related to these procedures,
and we have no way of discerning from our data whether the procedure
happened before or after the observation services.
The APC Panel made three recommendations related to these topics.
First, the Panel recommended that CMS add syncope and dehydration to
the list of clinical conditions eligible for separate observation
payment. However, the Panel requested that, if CMS added syncope and
dehydration to the list of conditions eligible for separate observation
payment, CMS reexamine the claims data once CMS collects a year of
observation claims data, including the additional conditions, so the
Panel could reconsider this recommendation at a future meeting. Second,
the Panel recommended that CMS continue to evaluate the types of
diagnostic conditions that might qualify for separate observation
payment in the future. Third, the Panel recommended that CMS make no
changes to the criteria for separate observation payment related to the
performance of ``T'' status procedures.
We have also taken into consideration the June 2006 IOM Report
entitled, ``Hospital-Based Emergency Care: At the Breaking Point.''
This report encourages hospitals to apply tools to improve the flow of
patients through emergency departments, especially through the use of
observation units (clinical decision units). The IOM report also
recommends that separate OPPS payment be made for all conditions for
which observation is indicated.
In the CY 2008 OPPS/ASC proposed rule, we indicated that, in light
of the broader CY 2008 OPPS proposal to move toward expanded packaging
of payment for supportive, dependent HOPD services, we were not
accepting the Panel's recommendation related to adding syncope and
dehydration to the list of diagnoses eligible for separate payment or
to consider other clinical conditions for separate payment for
observation care. Instead, we proposed to package all observation
services (reported with HCPCS code G0378) as part of the proposed
changes to packaged services discussed in section II.A.4. of the
proposed rule. Because we proposed to package payment for all
observation services, we did not propose to adopt the Panel's
recommendation to study claims data for separately payable observation
care (including claims for observation for syncope and dehydration)
that also include specific minor or routine procedures that have ``T''
status indicators. We agreed with the APC Panel and the IOM that there
is currently no compelling rationale for a different OPPS payment
approach for observation care for only three specific clinical
conditions. We recognized that observation care may play an important
role in the treatment of many Medicare beneficiaries in the HOPD,
decreasing the need for short inpatient admissions and ensuring safe
discharges of patients to their homes. Therefore, we stated that we
believe that the proposed CY 2008 payment policy that would package
payment for all observation services consistently for Medicare
beneficiaries regardless of their diagnoses is the most appropriate
approach in every case of observation care. We stated in the proposed
rule that the proposed methodology encourages hospital efficiency and
provides a consistent payment policy that allows hospitals to
thoughtfully plan for the role of observation services in the emergency
and postsurgical care of patients with many different clinical
conditions.
As discussed in section II.A.4.c. of the CY 2008 OPPS/ASC proposed
rule (and discussed in the same section of this final rule with comment
period), observation care is one of seven categories of services for
which we proposed to make packaged payment in CY 2008. In view of the
recent rapid growth in HOPD services, we proposed to move toward larger
payment packages and bundles under the OPPS because we believe that
packaging creates incentives for providers to furnish services in the
most efficient way by maximizing their flexibility to manage their
resources, thereby encouraging cost containment.
We proposed to package observation care reported with HCPCS code
G0378 for CY 2008 because of our belief that the facility portion of
observation care is supportive and ancillary to other primary services
being furnished in the HOPD. Payment for observation would be made as
part of the payment for the separately payable independent services
with which it is billed. We indicated in the CY 2008 OPPS/ASC proposed
rule that, as part of this proposal, we would change the status
indicator for HCPCS code G0378 from ``Q'' to ``N.'' Although we would
discontinue recognizing the criteria for separate payment related to
hospital visits and qualifying conditions, we indicated that we would
retain as general reporting requirements the criteria related to
physician evaluation, documentation and observation beginning and
ending time because those are more general requirements that help to
ensure proper reporting of observation on hospital claims. The criteria
for reporting of observation services under HCPCS code G0378 that we
proposed to retain are:
A. Observation Time
1. Observation time must be documented in the medical record.
2. A beneficiary's time in observation (and hospital billing)
begins with the beneficiary's admission to an observation bed.
3. A beneficiary's time in observation (and hospital billing) ends
when all clinical or medical interventions have been completed,
including followup care furnished by hospital staff and physicians that
may take place after a physician has ordered the patient to be released
or admitted as an inpatient.
B. Physician Evaluation
1. The beneficiary must be in the care of a physician during the
period of observation, as documented in the medical record by
admission, discharge, and other appropriate progress notes that are
timed, written, and signed by the physician.
2. The medical record must include documentation that the physician
explicitly assessed patient risk to determine that the beneficiary
would benefit from observation care.
At the September 2007 APC Panel meeting, the Observation and Visit
Subcommittee and the full Panel recommended that the work of the
subcommittee continue. After two presentations and robust discussion of
the proposal to package observation services, the Panel made two
additional recommendations. First, the Panel recommended that CMS not
finalize the proposal to implement observation services packaging for
CY 2008, stating that it would be detrimental for patients receiving
medically necessary services and would increase costs. The Panel also
requested that CMS provide specific data on observation in order to
understand trends and utilization for review at the 2008 winter meeting
of the Panel. This includes data related to inappropriate reporting or
overutilization of observation services; frequency and utilization data
for the three conditions for which observation services are now
separately payable; association of observation services with emergency
department and clinic visits; analysis of the frequency of claims for
[[Page 66813]]
observation services compared with the inpatient error rate; and a
frequency distribution showing length of stay data for observation
services.
Second, the Panel recommended that, if CMS finalizes the packaging
of observation services, CMS should create a composite emergency
department/clinic and observation APC (or a group of composite APCs)
that is only paid when both services are provided. The Panel added
that, if the composite APC is paid, neither the clinic nor emergency
department visit would be paid separately. Also, coding and service
requirements currently applicable to separately payable observation
would remain the same, with the exception that there would be no
clinical condition restriction on payment for the composite APC and
payment rates for this composite APC would need to be adjusted based on
readily available historical data. Finally, the Panel recommended that
CMS evaluate any potential negative impact that the CY 2008 packaging
proposal and the component specifically concerning observation would
have on Medicare beneficiaries. We accept the Panel's request that CMS
provide the Panel with further data related to observation services at
the next meeting of the APC Panel.
After considering the APC Panel presentations, the Panel
recommendations, and the public comments we received, we will neither
maintain the current CY 2007 payment methodology for observation
services nor implement the packaging proposal as proposed. Instead, we
are accepting the recommendation of the APC Panel and the commenters to
package observation services and provide payment through a composite
APC methodology when the specified criteria apply, as discussed in
detail in section II.A.4.c.(7) of this final rule with comment period.
We note that this payment methodology will require no changes to the
reporting practices of hospitals, so there should be no associated
administrative burden on hospitals. The OCE will determine the payment
for observation as packaged into a composite APC payment or packaged
into payment for other separately payable services provided in the
encounter.
As discussed earlier in section II.A.4.c.(7) of this final rule
with comment period, HCPCS code G0378 is assigned a status indicator
``N,'' meaning that its payment will always be packaged, either into
one of the two composite APCs or, when the composite criteria are not
met, into the payment for the major services on the claim. In addition,
we no longer require a qualifying diagnosis but, for the purposes of
composite APC payment, will retain all other criteria required in CY
2007 for separate observation care payment, including: a minimum number
of 8 hours; a qualifying visit, direct admission to observation care,
or critical care; and no ``T'' status procedure reported on the day
before or day of observation services. Additionally, we are retaining
the general reporting requirements for all observation services. These
are the requirements related to the physician order and evaluation,
documentation, and observation beginning and ending times. They are
more general criteria that ensure the proper reporting of observation
care on correctly coded hospital claims that reflect the charges
associated with all hospital resources utilized to provide the reported
services.
Comment: Many commenters, as well as the APC Panel, urged CMS to
consider the inpatient error rate as well as QIO review practices
before packaging observation services. Many commenters pointed to a
decrease in inpatient admissions as evidence of the impact of separate
payment for observation services on the decrease in hospital
admissions. In addition, several commenters were concerned about
pressure to bill 1 to 2 day stays as outpatient claims with
observation, resulting in confusion as to the appropriate billing for
observation services. For example, one commenter stated that care
provided during outpatient observation is no different than the care
and monitoring provided to an inpatient, often because patients in
observation may be placed in a bed within the inpatient setting. One
commenter requested that CMS review 1 to 2 day inpatient QIO denials
for accuracy of observation status utilization and denial
appropriateness.
Response: We appreciate the commenters' thoughts regarding the
impact of our OPPS payment policy to pay separately for observation
care for three clinical conditions on brief inpatient admissions. We
continue to believe that observation care is a clinically appropriate
hospital outpatient service that includes 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. We expect that
Medicare beneficiaries who require an inpatient level of care will be
admitted to the hospital as inpatients by the physicians who care for
them. We also believe that our final CY 2008 payment policy to pay for
extended assessment and management services that involve lengthy
observation through composite APCs should pay hospitals appropriately
for the services they provide as they are caring for patients until a
decision about inpatient admission or safe discharge can be made.
We will work to further educate hospitals, physicians, and all
Medicare contractors on appropriate billing for observation services.
We also will analyze the effects of our final CY 2008 OPPS payment
policy for observation services over time on patterns of Medicare
beneficiary inpatient admissions, high level clinic and ED visits, and
observation care.
Comment: Several commenters discussed the typical length of
observation stays as support for separate payment of observation care.
The stays in the comments ranged from 12 to 16 hours (in reference to
patients with chest pain) to 23 hours (in reference to patients in
dedicated observation units versus 2 to 3 day stays for inpatient
care). The topic was also discussed by the APC Panel, which requested
that CMS provide a frequency distribution of observation lengths of
stay at the next APC Panel meeting.
Response: We have stated in past rules and in the Internet Only
Manual (IOM) that, ``in only rare and exceptional cases do reasonable
and necessary outpatient observation services span more than 48 hours.
In the majority of cases, the decision whether to discharge the patient
from the hospital * * * or to admit the patient as an inpatient can be
made in less than 48 hours, usually in less than 24 hours.'' We refer
readers to the Medicare Claims Processing Manual, Pub. 100-4, Chapter
4, Section 290.1 for more information. We will conduct a study of
observation lengths of stay for the next APC Panel meeting. However,
preliminary analyses of CY 2006 claims for observation show that, of
all observation claims (packaged and paid separately), 43 percent
lasted 13 to 24 hours (about 358,600 claims), 37 percent lasted 24 to
48 hours (about 303,000 claims), and 3 percent lasted more than 48
hours (about 26,000 claims). Less than 10 percent of claims were for
observation lasting less than 8 hours, and about 8 percent of claims
were for stays of 8 to 12 hours. With respect to separately payable
observation, the numbers were very similar: 45 percent lasted 13 to 24
hours (133,000 claims), 38 percent lasted 24 to 48 hours (112,000
claims), and 3 percent lasted more than 48 hours (8,600 claims). The
mean and median number of hours were the same for packaged
[[Page 66814]]
and separately payable observation services: a mean of 25 hours and a
median of 22 hours.
We are concerned about the significant number of beneficiaries who
are receiving observation services for more than 24 hours, especially
the 26,000 with stays of more than 48 hours. This finding seems to
indicate that the latter stays are not as rare and exceptional as we
have stated they should be in the context of contemporary hospital
outpatient clinical practice. As we stated earlier in section
II.A.4.c.(7) of this final rule with comment period, we do not expect
to see an increase in claims for high level visits as a result of the
new composite APCs adopted for CY 2008. We also do not expect to see a
large increase in the number of claims or lengths of stay for
observation care. Depending on our future claims data, we may choose to
modify the composite APCs that we are adopting for CY 2008, or to move
to packaging observation services more broadly into payment for all
other associated services as we originally proposed, if we see that
observation care is being provided to many more patients than reflected
in our current data. Since we first established HCPCS code G0378 as an
hourly code for hospitals to report observation services beginning in
CY 2006, in accordance with our reporting instructions, hospitals have
been asked to report all observation services provided with HCPCS code
G0378.
Comment: Several commenters stated that providing care through
outpatient observation versus inpatient admission saves beneficiary
inpatient benefit days and decreases beneficiary expenses for the
inpatient deductible and coinsurance. The APC Panel also recommended
that we evaluate the effect of packaging on beneficiaries.
Response: We intend to evaluate the effects of packaging payment
for services, including observation care, on Medicare beneficiaries,
but note that it is not clear whether care provided through a hospital
outpatient observation stay would increase or decrease a beneficiary's
expenditures in comparison with an inpatient admission. In addition, as
stated earlier, we do not consider observation services and inpatient
care to be the same level of care and, therefore, they would not be
interchangeable and appropriate for the same clinical scenario. Under
the OPPS, the beneficiary copayment increases as the number and payment
amount of separately payable services on the claim increase. The OPPS
beneficiary copayment is 20 to 40 percent, depending on the service
provided. Therefore, to the extent that the resulting APC payments for
a specific set of services are less under the packaging approach we
have adopted for CY 2008, as many commenters have indicated they would
be, beneficiary copayment could be reduced. Additionally, the length of
stay may greatly impact beneficiary OPPS copayment as the number of
diagnostic tests and services provided may increase as the stay
lengthens. Also, self-administered drugs are excluded from Part B
payment by statute, whereas payment for those costs would be included
in an inpatient DRG payment. Therefore, a beneficiary placed in
observation care for an extended period could have a greater or lesser
out-of-pocket expense than for an inpatient stay, once all direct
beneficiary expenses are included.
In summary, we are adopting our proposal to package payment for
observation care reported with HCPCS code G0378 for CY 2008, with a
modification to establish two new composite APCs for extended
assessment and management. For CY 2008, payment for observation
services reported with HCPCS code G0378 will remain packaged with
status indicator ``N.'' We are creating two composite APCs for extended
assessment and management, of which observation care is a component. In
addition, we will not require a qualifying diagnosis for composite APC
payment, but for the purposes of composite APC payment, will retain all
other criteria, including a minimum number of eight hours; a qualifying
visit, direct admission, or critical care; and no ``T'' status
procedure reported on the day before or day of observation services.
Additionally, we are retaining the general reporting requirements for
all observation services, whether fully packaged or included in the
composite APC payment. These are criteria related to the physician
order and evaluation, documentation, and observation beginning and
ending times. These are the more general requirements that ensure the
proper reporting of observation care on correctly coded hospital claims
that reflect the charges associated with all hospital resources
utilized to provide the reported services.
B. Direct Admission to Observation (HCPCS code G0379)
For CY 2007, direct admission to observation (HCPCS code G0379
(Direct admission of patient for hospital observation care)) is
assigned to APC 0604 (Level 1 Hospital Clinic Visits) when the criteria
are met for separate payment. For CY 2008, the proposed median cost of
APC 0604 was approximately $53. We proposed to continue the current
coding and payment methodology for direct admission to observation,
with the exception of the prior requirement that HCPCS code G0379 is
only eligible for separate payment if observation care reported with
HCPCS code G0378 does not qualify for separate payment. That
requirement would no longer be applicable, given our CY 2008 proposal
to provide packaged payment for all observation care. Hospitals report
HCPCS code G0379 when a patient is admitted directly to observation
care after being seen by a physician in the community. Thus, for CY
2008, we proposed that in order to receive separate payment for a
direct admission into observation (APC 0604), the claim must show:
1. Both HCPCS codes G0378 (Hospital observation services, per hr)
and G0379 (Direct admission of patient for hospital observation care)
with the same date of service.
2. That no services with a status indicator ``T'' or ``V'' or
Critical Care (APC 0617) were provided on the same day of service as
HCPCS code G0379.
Even though we proposed to package payment for all observation
services reported by HCPCS code G0378, we indicated in the proposed
rule that we believe it is necessary to continue the OCE claims
processing logic in order to make appropriate payment for direct
admission.
We did not receive any public comments specific to our proposed
payment policy for HCPCS code G0379.
As explained in section II.A.4.c.(7) of this final rule with
comment period, payment for direct admission to observation will be
made either under composite APC 8002 (Level I Prolonged Assessment and
Management Composite) or under APC 0604. The composite APC will apply,
regardless of the patient's particular clinical condition, if the hours
of observation services (HCPCS code G0378) are greater than or equal to
eight and billed on the same date as HCPCS code G0378 and there is not
a ``T'' status procedure on the same date or day before the date of
HCPCS code G0378. If the composite is not applicable, payment for HCPCS
code G0379 may be made under APC 0604. In general, this would occur
when the units of observation reported under HCPCS code G0378 are less
than eight and no services with a status indicator ``T'' or ``V'' or
Critical Care (APC 0617) were provided on the same day of service as
HCPCS code G0379. The final median cost of APC 0604 for CY 2008 is
approximately $53. The criteria for payment of HCPCS code G0379 under
[[Page 66815]]
APC 0604 will be the same as in CY 2007:
1. Both HCPCS codes G0378 (Hospital observation services, per hr)
and G0379 (Direct admission of patient for hospital observation care)
with the same date of service.
2. No service with a status indicator of ``T'' or ``V'' or Critical
Care (APC 0617) is provided on the same day of service as HCPCS code
G0379.
If either of the above criteria is not met, HCPCS code G0379 will
be assigned status indicator ``N.''
Comment: One commenter asked CMS to clarify whether there is a
discrepancy between language describing observation time in the current
CY 2007 criteria for separate payment of observation services through
APC 0339, listed on page 42768 of the CY 2008 OPPS/ASC proposed rule
(72 FR 42628) and language in the Medicare Claims Processing Manual,
Pub. 100-4, Chapter 4, Section 290.2.2. The commenter requested
clarification as to whether a physician order is still required for
observation.
Response: The language cited in the CY 2008 OPPS/ASC proposed rule
and earlier in this section is also located in the Medicare Claims
Processing Manual, Pub. 100-4, Chapter 4, section 290.4.3 ``Separate
and Packaged Payment for Observation.'' Sections 290.2.2 and 290.4.3 do
not conflict, although the language is not identical. Section 290.2.2
is overarching guidance for the reporting of observation services that
supports and explains section 290.4.3. In regard to the requirement of
a physician order, although the words ``physician order'' are not
written in section 290.4.3, a physician order is clearly contemplated,
as the language in criterion number 4, Physician Evaluation, states,
``1. The beneficiary must be in the care of a physician during the
period of observation, as documented in the medical record by
admission, discharge, and other appropriate progress notes that are
timed, written, and signed by the physician. 2. The medical record must
include documentation that the physician explicitly assessed patient
risk to determine that the beneficiary would benefit from observation
care.'' This criterion will be retained under the new payment
methodology, as we proposed. Additionally, section 290.1 ``Observation
Services Overview'' explicitly states that ``Observation services are
only covered when provided by the order of a physician or another
individual authorized by State licensure law and hospital staff bylaws
to admit patients to the hospital or to order outpatient services.'' We
are not removing the physician order requirement. The IOM will be
revised to reflect the payment changes finalized in this final rule
with comment period. We will revise all sections for consistency and
accuracy, but we also remind hospitals that Section 290 of the Claims
Processing Manual should be read in its totality.
In summary, CY 2008 payment for HCPCS code G0379, direct admission
for hospital observation care, will be made either through composite
APC 8002 (Level I Extended Assessment and Management Composite) or APC
0604 (Level 1 Hospital Clinic Visits). In cases where the criteria for
payment under either APC are not met, HCPCS code G0379 is assigned
status indicator ``N.''
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 may
use any of 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 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 ASC and is on the list of approved ASC
procedures or has been 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 2008 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
removing 14 procedures from the OPPS inpatient list at its March 2007
meeting. Prior to publishing the CY 2008 OPPS/ASC proposed rule, we
received one other candidate HCPCS code for removal from the OPPS
inpatient list based on a recommendation from the public that was
presented to the APC Panel during its meeting on March 8, 2007. The APC
Panel recommended that 13 of the 14 procedures that CMS identified for
possible removal be removed from the OPPS inpatient list. It also
recommended that CMS obtain additional utilization data about 1 of the
14 procedures identified for possible removal from the OPPS inpatient
list, specifically CPT code 64818 (Sympathectomy, lumbar); and for
another procedure presented for possible removal from the OPPS
inpatient list by the public, specifically, CPT code 20660 (Application
of cranial tongs caliper, or stereotactic frame,
[[Page 66816]]
including removal (separate procedure)). The APC Panel requested that
CMS provide that additional information to the APC Panel at its next
meeting.
Therefore, in the CY 2008 OPPS/ASC proposed rule (72 FR 42771), we
proposed to accept the APC Panel's recommendation to remove the 13
procedures from the OPPS inpatient list for CY 2008 and to assign them
to clinically appropriate APCs as shown in Table 56 of the proposed
rule and republished in this final rule with comment period as Table
46. In the proposed rule, we indicated that we also are accepting the
recommendation from the APC Panel to gather additional utilization
information for CPT codes 20660 and 64818, which we would provide to
the APC Panel at its next meeting.
We received several comments in response to our proposal for the CY
2008 OPPS inpatient list. A summary of the comments and our responses
follows.
Comment: A few commenters supported the proposal to remove the 13
codes listed in Table 56 of the proposed rule from the inpatient list
for CY 2008. One commenter requested that, for CY 2009, CMS reassess
the APC assignment for CPT code 61770 (Stereotactic localization,
including burr hole(s), with insertion of catheter(s) or probe(s) for
placement of radiation source). The commenter supported the proposed CY
2008 assignment of CPT code 61770 to APC 0221 (Level II Nerve
Procedures) but asked CMS to ensure that, as data become available, CMS
makes appropriate adjustments to the APC assignment for this CPT code.
Response: We appreciate the commenters' support and will review the
APC assignment for CPT code 61770, and all other procedures payable
under the OPPS, when updating the OPPS for CY 2009, in order to
maintain clinical and resource homogeneity within APCs.
After consideration of the public comments received, we are
finalizing our proposal, without modification, to remove 13 procedures
from the OPPS inpatient list for CY 2008 and to assign them to
clinically appropriate APCs as shown in Table 46 below. Also, as stated
earlier, we will present data regarding CPT codes 20660 and 64818 to
the APC Panel at its winter 2008 meeting. We note that we did not have
additional new data available for CPT code 20660 for the APC Panel to
consider at its September 2007 meeting.
Table 46.--HCPCS Codes for Removal From Inpatient List and Their APC
Assignments for CY 2008
------------------------------------------------------------------------
HCPCS code Long descriptor CY 2008 APC CY 2008 SI
------------------------------------------------------------------------
21360............. Open treatment of 0254 T
depressed malar
fracture,
including
zygomatic arch
and malar tripod.
21365............. Open treatment of 0256 T
complicated
(e.g.,
comminuted or
involving
cranial nerve
foramina)
fracture(s) of
malar area,
including
zygomatic arch
and malar
tripod; with
internal
fixation and
multiple
surgical
approaches.
21385............. Open treatment of 0256 T
orbital floor
blowout
fracture;
transantral
approach
(Caldwell-Luc
type operation).
25931............. Transmetacarpal 0049 T
amputation; re-
amputation.
27006............. Tenotomy, 0050 T
abductors and/or
extensor(s) of
hip, open
(separate
procedure).
27720............. Repair of 0063 T
nonunion or
malunion, tibia;
without graft,
(eg, compression
technique).
27722............. Repair of 0064 T
nonunion or
malunion, tibia;
with sliding
graft.
50580............. Renal endoscopy 0161 T
through
nephrotomy or
pyelotomy, with
or without
irrigation,
instillation or
ureteropyelograp
hy, exclusive of
radiologic
service; with
removal of
foreign body or
calculus.
51535............. Cystotomy for 0162 T
excision,
incision, or
repair of
ureterocele.
58805............. Drainage of 0195 T
ovarian cyst(s),
unilateral or
bilateral,
(separate
procedure);
abdominal
approach.
60271............. Thyroidectomy, 0256 T
including
substernal
thyroid;
cervical
approach.
61770............. Stereotactic 0221 T
localization,
including burr
hole(s), with
insertion of
catheter(s) or
probe(s) for
placement of
radiation source.
69970............. Removal of tumor, 0256 T
temporal bone.
------------------------------------------------------------------------
Comment: Several commenters submitted recommendations for improving
the effectiveness of the inpatient list. One commenter stated that
although CMS believes that the inpatient list is serving a protective
purpose, the payment policy and the format for the list limit its
effectiveness. The commenter recommended a number of steps that CMS
could take to improve the usefulness of the inpatient list. The first
of these recommendations was for CMS to provide the CPT code long
descriptors for the procedures on the inpatient list instead of listing
the procedures' CPT code short descriptors. The commenter stated that
the short descriptors do not provide enough information for hospital
staff and physicians to readily determine in a specific clinical case
whether a planned procedure is, or is not, on the inpatient list. The
commenter believed that inclusion of the long descriptors would make
the CMS inpatient list a more useful and readily available tool that
could be used during outpatient scheduling. Further, the commenter
believed that easier access to the long descriptors would assist
hospital staff in scheduling, promote appropriate physician planning,
and provide time to notify any affected beneficiary of his or her
liability if an inpatient list procedure is to be performed in the OPD.
In addition, the commenter recommended that CMS consider developing
a code that would enable hospitals to indicate to Medicare those cases
in which the physician failed, or refused, to notify the patient that
the procedure was on the inpatient list and would not be paid by
Medicare if performed in the hospital outpatient setting. The commenter
suggested that the physician could then be held accountable for those
cases, and Medicare could track physicians who repeatedly chose
inappropriate admission status for procedures on the inpatient list.
Further, the commenter recommended that CMS implement financial
disincentives for physicians' performance of the inpatient list
procedures in the HOPD through proposed professional payment reductions
and/or practice audits of physicians who repeatedly perform these
procedures in inappropriate settings.
The commenter also recommended that CMS consider expanding the
ability
[[Page 66817]]
of hospital staff and utilization review committees to overturn
outpatient status orders when procedures on the inpatient list are
performed, but the services are either not reported timely by the
attending physician or are not revised upon notification of the status
conflict.
Finally, the commenter recommended that if CMS is not willing to
refocus the payment policy associated with the inpatient list to
address physician behavior, it should drop the inpatient list
altogether because the list presents a financial burden that
beneficiaries and hospitals are no longer willing to bear on behalf of
noncompliant and noncooperative physicians.
A number of other commenters also recommended that CMS discontinue
use of the inpatient list. They stated that the continuing problem
associated with the list is that the list is not binding on physicians
and that, therefore, efforts by hospitals to educate them are useless.
Response: We appreciate the recommendations for improving the
effectiveness of the inpatient list. We continue to believe that the
inpatient list serves an important purpose in identifying those
procedures that cannot be safely and effectively provided to Medicare
beneficiaries in the HOPD. We are concerned that elimination of the
inpatient list could result in unsafe or uncomfortable care for
Medicare beneficiaries and, therefore, we will not discontinue our use
of the inpatient list at this time. While we are aware that there are
ongoing hospital concerns related to inpatient procedures being
performed inappropriately for beneficiaries who are not inpatients and
that, as a result, beneficiaries may be liable for the charges for the
services, among the potential results of eliminating the list are long
observation stays after some procedures and imposition of OPPS
copayments that could differ significantly from a beneficiary's
inpatient cost-sharing responsibilities.
In addition, we have no current plans to develop coding that would
permit us to identify cases of the outpatient performance of inpatient
listed procedures on Medicare beneficiaries because information on such
occurrences is currently available in our OPPS claims data. Payment for
physicians' services and monitoring of physicians' practice patterns
are outside of the scope of this OPPS/ASC final rule with comment
period. We continue to believe that it is very important for hospitals
to educate physicians on Medicare services covered under the OPPS to
avoid inadvertently providing services in a hospital outpatient setting
that only are covered during an inpatient stay.
We will explore the feasibility of the commenter's recommendation
that CMS could assist hospitals in this effort by providing the CPT
code long descriptors for the inpatient list (Addendum E to this final
rule with comment period). CMS' use of CPT code short and long
descriptors is governed by its agreement with the AMA, the owner and
maintainer of the CPT codeset. If we are able to provide a listing of
long descriptors for the inpatient list procedures, we will post that
information to the CMS Web site as soon as it is available. We believe
that enhanced information regarding specific procedures may foster
increased understanding by physicians about the status of the inpatient
list procedures and the payment implications for beneficiaries and
hospitals when the procedures are performed on beneficiaries who are
not admitted to the hospital.
Comment: Several commenters recommended that if CMS does not
eliminate the inpatient list, it should consider developing an appeals
process to address those circumstances in which payment for a service
is denied because it is on the inpatient list. One commenter asserted
that the process would provide an opportunity for the hospital to
submit documentation to appeal the denial, such as physician intent,
patient clinical condition, and the circumstances that allowed the
patient to be sent home safely without an inpatient admission.
Response: We appreciate these comments and suggestions. As we
stated in the immediately preceding response, 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 intend to continue
to encourage physicians' awareness of the implications for
beneficiaries of performing the inpatient list procedures on
beneficiaries who are not inpatients. We do not plan to adopt a
specific appeals process for claims related to inpatient list
procedures performed in the HOPD, as recommended by some commenters, at
this time. However, the existing established processes for a
beneficiary or provider to appeal a specific claim remain in effect.
Comment: Two commenters requested that CMS remove certain
procedures from the inpatient list. One commenter requested that CMS
remove the following three CPT codes that were proposed for removal
from the inpatient list in the CY 2008 proposed rule: 25931
(Transmetacarpal amputation; re-amputation), 27006 (Tenotomy, abductors
and/or extensor(s) of hip, open (separate procedure), and 27720 (Repair
of nonunion or malunion, tibia; without graft, (eg, compression
technique)).
The other commenter requested that CMS remove the following four
additional CPT codes from the inpatient list: 20660 (Application of
cranial tongs, caliper, or stereotactic frame, including removal),
27886 (Amputation, leg, through tibia and fibula; reamputation), 43420
(Closure of esophagostomy or fistula; cervical approach) and 50727
(Revision of urinary-cutaneous anastomosis (any type urostomy)).
Response: As discussed earlier in this section, we are finalizing
our proposal to remove CPT codes 25931, 27006, and 27720 from the OPPS
inpatient list for CY 2008.
We appreciate the additional recommendations for procedures to be
removed from the inpatient list. We note that CPT code 20660 was
discussed at the APC Panel's March 2007 meeting and, in accordance with
the APC Panel's recommendation, we will provide utilization information
regarding this service at the APC Panel's winter 2008 meeting for its
consideration. We will undertake a clinical review of the additional
procedures requested for removal from the inpatient list for CY 2008.
However, we will not remove those procedures from the inpatient list
without obtaining additional input from the APC Panel. We will provide
appropriate information on CPT codes 27886, 43420, and 50727 to the APC
for its review of these procedures at the APC Panel's winter 2008
meeting, along with other procedures that we may identify as candidates
for proposed removal from the inpatient list for CY 2009.
XIII. Nonrecurring Technical and Policy Changes
A. Outpatient Hospital Services and Supplies Incident to a Physician
Service
In the CY 2008 OPPS/ASC proposed rule (72 FR 42771), we proposed to
make a technical change to Sec. 410.27(a)(1)(iii) and (f) of the
regulations relating to outpatient hospital services and supplies
incident to a physician service to remove an outdated reference to
``designation of a department of a provider'' by CMS and replace it
with language that conforms to current policy under the provider-based
rules as stated in Sec. 413.65 of the regulations. We proposed to
remove from both paragraphs (a)(1)(iii) and (f) the phrase ``at a
location (other than an RHC or an FQHC) that CMS designates as a
department of a provider under
[[Page 66818]]
Sec. 413.65 of this chapter'' and replace it with ``at a department of
a provider, as defined in Sec. 413.65(a)(2) of this subchapter, that
has provider-based status in relation to a hospital under Sec. 413.65
of this subchapter.''
Section 410.27 was codified in the April 7, 2000 OPPS final rule
with comment period. The provider-based rules at Sec. 413.65 were also
codified in the April 7, 2000 rule, but were subsequently amended in
the August 1, 2002 IPPS final rule (67 FR 50078 through 50096 and 50114
through 50118). The proposed deletion of the reference in Sec.
410.27(a)(1)(iii) and (f) to CMS ``designating'' a department of a
provider under Sec. 413.65 would make those sections consistent with
the 2002 amendments to the provider-based rules, in that under the
amended provider-based rules, a main provider is no longer required to
ask CMS to make a determination that a facility or organization is
provider-based before the main provider can bill for services of the
facility as if the facility were provider-based, or before the main
provider can include the costs of those services in its cost report.
In the proposed rule, we also reminded hospitals of the
requirements of Sec. 410.27 concerning services and supplies furnished
incident to a physician's service to hospital outpatients. Section
410.27 applies to all ``incident to'' services covered under section
1861(s)(2)(B) of the Act. This provision does not apply to services
covered under other benefit categories, such as clinical diagnostic
laboratory services covered under section 1833(h)(1) of the Act or
diagnostic services covered under section 1861(s)(2)(C) of the Act.
Section 410.27(a)(1) currently states that Medicare Part B pays for
hospital services and supplies furnished incident to a physician
service to outpatients, including drugs and biologicals that cannot be
self-administered, if they are furnished by or under arrangements made
by a participating hospital, except in the case of a resident of a
skilled nursing facility as provided in Sec. 411.15(p); as an integral
though incidental part of a physician's services; and in the hospital
or at a location (other than a rural health clinic or a Federally
qualified health center) that CMS designates as a department of a
provider under Sec. 413.65.
As discussed in the CY 2008 OPPS/ASC proposed rule, we recognize
that hospitals consider a variety of business models in their efforts
to supply efficient and high quality health care services to Medicare
beneficiaries and the general public, and we support such efforts to
the extent that they comply with all applicable laws and regulations,
including, but not limited to, the Stark law and other anti-kickback
laws. Recently, we have received an increasing number of questions
about a number of hypothetical business arrangements between hospitals
and other entities, including ASCs. We remind hospitals contemplating
various business models that involve ``incident to'' services provided
to hospital outpatients to consider the requirements of Sec. 410.27.
Under Sec. 410.27, ``incident to'' services that are provided to
hospital outpatients must be furnished in the hospital or at a
department of a provider as described in more detail earlier in our
proposed technical update to Sec. 410.27(a)(1)(iii) and (f).
With regard to the potential for ASCs to provide ``incident to''
services under arrangements with HOPDs, in the proposed rule, we noted
that the provider-based rules set forth at Sec. 413.65 do not apply to
ASCs. In addition, our longstanding policy codified at Sec. 416.30(f)
for ASCs operated by hospitals requires that ``the ASC participates and
is paid only as an ASC, without the option of converting to or being
paid as a hospital outpatient department, unless CMS determines there
is good cause to do otherwise.'' In the proposed rule, we indicated
that we did not believe good cause exists such that a Medicare-
certified ASC would be able to provide ``incident to'' services under
arrangement to hospital outpatients under Sec. 410.27. Section 410.27
contains longstanding policy codified in the CY 2000 OPPS final rule
with comment period and applies to all ``incident to'' services covered
under section 1861(s)(2)(B) of the Act. While the hypothetical example
we discussed above involves ASCs providing services under arrangement
to an HOPD, the provision of Sec. 410.27 applies more broadly to all
``incident to'' services provided either directly or under arrangements
made by the hospital with another entity.
Comment: One commenter generally supported the proposed technical
change to Sec. 410.27(a)(1)(iii) and (f), but cautioned CMS against
precluding a hospital's ability to offer the best patient care by
limiting physician and hospital relationships.
Response: We appreciate the commenter's support for the proposed
technical change. We do support hospitals' efforts to develop business
models that lead to the provision of high quality patient care to the
extent that these models comply with all applicable laws and
regulations, including, but not limited to, the Stark law and other
anti-kickback laws.
After consideration of the public comment received, we are
finalizing our CY 2008 proposal, without modification, to remove from
both paragraphs (a)(1)(iii) and (f) of Sec. 410.27 the phrase ``at a
location (other than an RHC or an FQHC) that CMS designates as a
department of a provider under Sec. 413.65 of this chapter.'' In place
of the deleted phrase, we are inserting the phrase ``at a department of
a provider, as defined in Sec. 413.65(a)(2) of this subchapter, that
has provider-based status in relation to a hospital under Sec. 413.65
of this subchapter.'' This finalized technical change removes an
outdated reference to ``designation of a department of a provider'' by
CMS and replaces it with language that conforms to current policy under
the provider-based rules specified in Sec. 413.65 of the regulations.
B. Interrupted Procedures
Currently, when a procedure is interrupted after its initiation or
the administration of anesthesia, hospitals append modifier 74
(Discontinued outpatient procedure after anesthesia administration) to
the interrupted procedure, and the full OPPS payment for the procedure
is made. In addition, when a procedure requiring anesthesia is
discontinued after the beneficiary is prepared for the procedure and
taken to the room where the procedure is to be performed, but before
the administration of anesthesia, hospitals currently append modifier
73 (Discontinued outpatient procedure prior to anesthesia
administration) to the discontinued procedure and receive 50-percent of
the OPPS payment for the planned procedure. Hospitals also report
modifier 52 to signify that a service that did not require anesthesia
was partially reduced or discontinued at the physician's discretion.
Modifier 52 is reported under the OPPS for a variety of types of
interrupted services, such as radiology services. Under the OPPS, we
apply a 50-percent reduction to the facility payment for interrupted
procedures and services reported with modifier 52.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42772), we proposed to
amend Sec. 419.44 (Payment reductions for surgical procedures) to more
accurately reflect the current OPPS payment policy for interrupted
procedures. First, we proposed to make a technical conforming change to
the title of Sec. 419.44 by removing the word ``surgical,'' in order
to encompass all the procedures performed in HOPDs. Second, we proposed
to change the
[[Page 66819]]
heading of Sec. 419.44(b) from ``Terminated procedures'' to
``Interrupted procedures.'' We proposed to make further technical
conforming changes to paragraphs (b)(1) and (b)(2) by removing the
words ``surgical'' to encompass all the procedures performed in HOPDs.
Finally, we proposed to add a new paragraph (b)(3) to reflect the
current policy of the application of a 50-percent reduction to the OPPS
payment when a hospital reports modifier 52 for interrupted or
discontinued services that do not require anesthesia.
Comment: One comment supported our proposed changes to Sec.
419.44.
Response: We appreciate the commenter's support of our proposed
changes.
After consideration of the public comment received, we are
finalizing the proposed changes to Sec. 419.44, as described above,
without modification.
C. Transitional Adjustments--Hold Harmless Provisions
Section 419.70(d) of the regulations relating to transitional
adjustments to payments for covered outpatient services furnished by
small rural hospitals and SCHs located in rural areas contains two
outdated cross-references to Sec. 412.63(b) (the definition of a
hospital located in a ``rural area''). Several years ago, we made Sec.
412.63 applicable from FY 1984 through FY 2004 and established a new
Sec. 412.64, effective for FY 2005 and subsequent fiscal years, to
incorporate provisions to reflect our adoption of OMB's revised CBSAs
as geographic area applicable under Medicare. In the CY 2008 OPPS/ASC
proposed rule (72 FR 42772), we proposed to make a technical correction
to the regulations by replacing the cross-reference to Sec. 412.63(b)
in Sec. Sec. 419.70(d)(1)(i), (d)(2)(i), and (d)(4)(ii) with the more
current applicable cross-reference to Sec. 412.64(b).
We did not receive any public comments on our proposal. Therefore,
we are finalizing the proposed technical correction, without
modification, for CY 2008.
D. Reporting of Wound Care Services
Section 1834(k) of the Act, as added by section 4541 of the BBA,
requires payment under a prospective payment system for all outpatient
therapy services, that is, physical therapy services, speech-language
pathology services, and occupational therapy services. As provided
under section 1834(k)(5) of the Act, we created a therapy code list
based on a uniform coding system (that is, the HCPCS) to identify and
track these outpatient therapy services paid under the MPFS. We provide
this list of therapy codes along with their respective designation in
the Medicare Claims Processing Manual Pub. 100-04, Chapter 5, section
20. Two of the designations that we use in that manual denote whether
the listed therapy code is an ``always therapy'' service or a
``sometimes therapy'' service. We define an ``always therapy'' service
as a service that must be performed by a qualified therapist under a
certified therapy plan of care, and a ``sometimes therapy'' service as
a service that may be performed by an individual outside of a certified
therapy plan of care.
In the CY 2006 OPPS final rule with comment period (70 FR 68617),
we stated that the following CPT codes were classified as ``sometimes
therapy'' services that may be appropriately provided under either a
certified therapy plan of care or without a certified therapy plan of
care: 97597 (Removal of devitalized tissue from wound(s), selective
debridement, without anesthesia (e.g., high pressure waterjet with/
without suction, sharp selective debridement with scissors, scalpel and
forceps) with or without topical application(s) for ongoing care, may
include use of a whirlpool, per session; total wound(s) surface area
less than or equal to 20 square centimeters); 97598 (Removal of
devitalized tissue from wound(s), selective debridement, without
anesthesia (e.g., high pressure waterjet with/without suction, sharp
selective debridement with scissors, scalpel and forceps) with or
without topical application(s) for ongoing care, may include use of a
whirlpool, per session; total wound(s) surface area greater than 20
square centimeters); 97602 (Removal of revitalized tissue from
wound(s), non-selective debridement, without anesthesia (e.g., wet-to-
moist dressings, enzymatic, abrasion) including topical application(s),
wound assessment, and instruction(s) for ongoing care, per session),
97605 (Negative pressure wound therapy (e.g., vacuum assisted drainage
collection), including topical application(s), wound assessment, and
instruction(s) for ongoing care, per session; total wound(s) surface
area less than or equal to 50 square centimeters); and 97606 (Negative
pressure wound therapy (e.g., vacuum assisted drainage collection),
including topical application(s), wound assessment, and instruction(s)
for ongoing care, per session; total wound(s) surface area greater than
50 square centimeters). We further stated that hospitals would receive
separate payment under the OPPS when they bill for wound care services
described by CPT codes 97597, 97598, 97602, 97605, and 97606 that are
furnished to hospital outpatients by individuals independent of a
therapy plan of care. In contrast, when such services are performed by
a qualified therapist under a certified therapy plan of care, providers
should attach an appropriate therapy modifier (that is, GP for physical
therapy, GO for occupational therapy, and GN for speech language
pathology) or report their charges under a therapy revenue code (that
is, 0420, 0430, or 0440), or both, to receive payment under the MPFS.
The OCE logic assigns these services to the appropriate APC for payment
under the OPPS if the services are not provided under a certified
therapy plan of care or directs contractors to the MPFS established
payment rates if the services are identified on hospital claims with a
therapy modifier or therapy revenue code as therapy services.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42772), we proposed to
revise the list of therapy revenue codes that may be reported with CPT
codes 97597, 97598, 97602, 97605, and 97606 to designate them as
services that are performed by a qualified therapist under a certified
therapy plan of care, and thus payable under the MPFS, to be consistent
with the current billing practices of hospitals and to ensure that we
are making separate payment under the OPPS only in appropriate
situations. We proposed to revise the list of therapy revenue codes for
reporting these five CPT wound care codes as therapy services to
include all revenue codes in the 042X series, which incorporates all
revenue codes that begin with 042, such as 0420, 0421, 0422, 0423,
0424, and 0429; the 043X series, which includes all revenue codes that
begin with 043, such as 0430, 0431, 0432, 0434, and 0439; and the 044X
series, which includes all revenue codes that begin with 044, such as
0440, 0441, 0442, 0443, 0444, and 0449. Therefore, for CY 2008, we
proposed that when services reported with CPT codes 97597, 97598,
97602, 97605, and 97606 are performed by a qualified therapist under a
certified therapy plan of care, providers should attach an appropriate
therapy modifier (that is, GP for physical therapy, GO for occupational
therapy, and GN for speech-language pathology) or report their charge
under a therapy revenue code (that is, 042X,043X, or 044X), or both, to
receive payment under the MPFS. Under other circumstances, we proposed
that hospitals would receive separate payment under the OPPS when they
bill for wound care services
[[Page 66820]]
described by CPT codes 97597, 97598, 97602, 97605, and 97606 that are
furnished to hospital outpatients by individuals independent of a
certified therapy plan of care.
We received several comments on our proposal to modify the list of
therapy revenue codes that are reported with certain wound care
services to signify that those services were provided by a qualified
therapist under a certified therapy plan of care.
Comment: Several commenters supported the proposal to modify the
revenue code list to conform to hospital billing practices. One
commenter opposed the proposal; the commenter stated that changing CPT
codes 97597, 97598, 97602, 97605, and 97606 to ``always therapy'' codes
and revising the list of revenue codes that may be reported with these
wound care codes would unreasonably restrict the use of the codes to a
limited group of health care providers, thereby limiting beneficiaries'
access to care.
Response: We appreciate the commenters' support for our proposal.
We believe the commenter who expressed concern about the proposal has
misunderstood our explanation of the proposal. We did not propose to
change the five CPT codes for wound care from ``sometimes therapy'' to
``always therapy'' codes. Hospitals will be paid for these wound care
codes under either the OPPS or the MPFS in CY 2008, just as they have
been since CY 2006. When hospital outpatients receive wound care
services by individuals outside of a certified therapy plan of care,
the hospital reports the appropriate CPT code and nontherapy revenue
code and is paid under the OPPS. When these services are provided to
hospital outpatients by a qualified therapist under a therapy plan of
care and reported using either one of the appropriate therapy
modifiers, the therapy revenue code series (42X, 43X, or 44X), or both,
hospitals are paid based on the MPFS. We proposed to make this minor
conforming change to make our billing policy consistent with the
current billing practices of hospitals. Therefore, we do not expect the
change to affect Medicare beneficiaries' access to wound care services
provided by hospitals.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to pay for
certain wound care services as therapy services when they are reported
with any revenue code in the 42X, 43X, or 44X series.
E. Reporting of Cardiac Rehabilitation Services
Since the initiation of the OPPS, Medicare has paid for cardiac
rehabilitation services in HOPDs using CPT code 93797 (Physician
services for outpatient cardiac rehabilitation, without continuous ECG
monitoring (per session)) and CPT code 93798 (Physician services for
outpatient cardiac rehabilitation, with continuous ECG monitoring (per
session)). Both codes are assigned status indicator ``S'' and are
currently mapped to APC 0095 (Cardiac Rehabilitation) for payment.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42773), for CY 2008,
we proposed to discontinue recognizing the current CPT codes for
cardiac rehabilitation services and to establish two new Level II HCPCS
codes that we believed would be more appropriate for specifically
reporting cardiac rehabilitation services under the OPPS. The proposed
HCPCS codes were: GXXX1 (Physician services for outpatient cardiac
rehabilitation; without continuous ECG monitoring (per hour)) and GXXX2
(Physician services for outpatient cardiac rehabilitation; with
continuous ECG monitoring (per hour)). In contrast with the current CPT
codes, we indicated that we believed the descriptors of these proposed
G-codes more specifically reflect the way cardiac rehabilitation
services are provided in HOPDs so that reporting would be more
straightforward for hospitals and would result in more accurate data
for OPPS ratesetting in 2 years. Consistent with the current APC
assignments of the cardiac rehabilitation CPT codes, we proposed to
assign these new HCPCS codes to APC 0095 for CY 2008, with a status
indicator of ``S.'' Accordingly, we proposed to change the status
indicators for CPT codes 93797 and 93798 from ``S'' to ``B'' to
indicate that alternative codes (GXXX1 and GXXX2) for cardiac
rehabilitation services would be recognized for payment under the OPPS.
At the September 2007 meeting of the APC Panel, after a public
presentation pertaining to the proposed coding change, the Panel
recommended that CMS continue to use the existing CPT codes for cardiac
rehabilitation services (CPT codes 93797 and 93798) and not replace
them with the proposed per hour HCPCS G-codes, GXXX1 and GXXX2.
We received many public comments on our CY 2008 proposal to adopt
two new G-codes, rather than continue to use the two available CPT
codes, for the reporting of cardiac rehabilitation services under the
OPPS. A summary of the public comments and our responses follow.
Comment: Some commenters supported the proposal to use G-codes for
the reporting of cardiac rehabilitation services under the CY 2008
OPPS. They believed that this proposed coding change would allow for
more appropriate coding and payment for cardiac rehabilitation services
in those cases where intensive programs provide multiple sessions each
day. The commenters argued that appropriate payment for these programs
was particularly important because of their success in improving the
health and health outcomes of patients through secondary prevention. In
addition, the commenters requested that CMS explicitly state that
multiple sessions of cardiac rehabilitation can be paid for the same
date of service when modifier 59 is reported. They also requested that
CMS crosswalk the payments for both of the proposed G-codes to the
higher cost CPT code 93798 to ensure that the full range of modalities
provided in certain intensive cardiac rehabilitation programs are
available.
Many commenters opposed the proposed change to G-codes under the
OPPS for several reasons. First, they stated that the proposed change
would pose an administrative burden on hospitals, which would have to
report G-codes on Medicare claims and CPT codes on claims to all other
payers. Although the commenters asserted that most cardiac
rehabilitation sessions last for approximately 1 hour, they explained
that it would be difficult to accurately crosswalk codes reported for
each hour of service to codes reported for each session, in order to
ensure that Medicare and other payers were charged the same for like
services. Second, some commenters argued that CMS would gather no new
useful data with the reporting of ``per hour'' codes because over 90
percent of cardiac rehabilitation programs provide sessions lasting
about 1 hour (specifically 45 minutes to 1\1/2\ hours), and costs from
historical hospital claims data and payment rates for the ``per
session'' CPT codes have been stable for years. A few commenters also
stated that this proposal conflicts with the National Coverage
Determination (NCD) for cardiac rehabilitation, which describes cardiac
rehabilitation coverage in terms of sessions. They also stated that the
proposal does not comport with CMS' CY 2008 proposed packaging approach
and CMS' stated goal of using CPT codes and CPT coding guidelines.
Almost all of the commenters, both supporting and opposing the
proposal,
[[Page 66821]]
were concerned that the use of the term ``physician services'' in the
G-code descriptors could be misinterpreted by Medicare contractors as
requiring a physician to directly deliver the care or be in attendance
during each service episode.
Some commenters who recommended the adoption of the proposed G-
codes requested that CMS provide additional guidance related to
reporting of the cardiac rehabilitation G-codes, such as: (1)
Explaining that it is likely to be reasonable and necessary to cover 72
cardiac rehab sessions when multiple sessions are provided in one day;
(2) encouraging contractors to factor the ``proven results'' of a
program into coverage decisions and that 72 sessions should be
``presumptively covered'' when they are furnished by a certain
intensive cardiac rehabilitation program; and (3) providing further
clarification and expansion of nutritional counseling by registered
dieticians, indicating that they could independently bill for
nutritional counseling within cardiac rehabilitation programs using the
medical nutrition therapy codes because the NCD does not specifically
mention these services.
Response: We understand hospitals' concerns related to the
administrative burden associated with reporting cardiac rehabilitation
services for Medicare differently from other payers and related to the
potential reporting confusion that could be caused by moving to G-codes
for the many hospitals whose program sessions last about 1 hour per
day. However, we also are aware of several intensive cardiac
rehabilitation programs that provide multiple sessions in a day,
lasting several hours total. Current OPPS payment policy would provide
payment for only one session per day for cardiac rehabilitation. The
NCD for cardiac rehabilitation currently states that cardiac
rehabilitation programs are covered for certain categories of patients
and they must be comprehensive. To be comprehensive, the programs must
include a medical evaluation, a program to modify cardiac risk factors
(for example, nutritional counseling), prescribed exercise, education,
and counseling. The NCD does not distinguish between different
approaches to the delivery of cardiac rehabilitation services, whether
the more common practice of two sessions per week or the more intensive
programs of several sessions per day. We have not been prescriptive
regarding the precise amount of time that must be spent on each
component of the program to allow for flexibility and tailoring based
on patient needs. Regarding intensity, we expect the intensity of
cardiac rehabilitation programs to vary by patient and by program.
We believe that it is important that our CY 2008 OPPS payment
policy provide appropriate payment for cardiac rehabilitation services.
In order to minimize the administrative burden on hospitals related to
our proposal but permit accurate reporting and payment for cardiac
rehabilitation programs that provide more than one session per day, we
believe that continuing the use of CPT codes 93797 and 93798 and
allowing hospitals to bill more than one session per day under some
circumstances would be the most appropriate course. Therefore, for CY
2008, we will allow hospitals to report more than one unit for a date
of service if more than one cardiac rehabilitation session lasting at
least 1 hour each is provided on the same day. We will provide a
separate APC payment for each reported session.
We note that the concern of some commenters regarding crosswalking
of payment for the two proposed ``per hour'' G-codes to CPT code 93798
is not an issue under the OPPS because we will be continuing to use
both CPT codes that map to the same clinical APC for payment in CY
2008. With respect to the commenters' concerns about the use of the
term ``physician services'' in the proposed G-code descriptors, we note
that these codes were proposed to be parallel to the descriptors of the
CPT codes for cardiac rehabilitation sessions that contain the term
``physician services'' in their descriptors. We are not aware that
hospitals have problems with Medicare contractors' interpretation of
the CPT codes, which we will continue to use for CY 2008.
This approach adopts the recommendation of the APC Panel and many
commenters, as well as addresses some commenters' concerns about
payment for appropriate cardiac rehabilitation services. We expect that
most cardiac rehabilitation programs will continue to provide
approximately 1 hour long session per date of service. We will monitor
the trends in our claims data to ensure that reporting of cardiac
rehabilitation remains consistent with expected patterns of
utilization. We will provide coding and payment instructions for
cardiac rehabilitation services in the program instructions
implementing the January 2008 OPPS update. We will not provide the
additional coverage-related guidance requested by some commenters, such
as presumptive coverage and independent billing for registered
dieticians. These recommendations effectively request changes to the
NCD and, therefore, are outside of the scope of the OPPS and this final
rule with comment period.
After consideration of the public comments received, we are not
finalizing our proposal to establish two new G-codes for reporting
cardiac rehabilitation services. Instead, we will continue to use CPT
codes 93797 and 93798 to report cardiac rehabilitation services under
the CY 2008 OPPS. CPT codes 93797 and 93798 are assigned to APC 0095
(Cardiac Rehabilitation), with a CY 2008 median cost of approximately
$36 and status indicator ``S.'' Beginning in CY 2008, we will allow
hospitals to report more than one unit of service per day if more than
one cardiac rehabilitation session lasting at least 1 hour each is
provided on the same day, but will monitor the claims data to ensure
that utilization of cardiac rehabilitation services remains
appropriate.
F. Reporting of Bone Marrow and Stem Cell Processing Services
The OPPS has historically recognized HCPCS code G0267 (Bone marrow
or peripheral stem cell harvest, modification or treatment to eliminate
cell type(s)) for depletion services for hematopoietic progenitor
cells, instead of the more specific CPT codes that describe these
services, including CPT codes 38210 (Transplant preparation of
hematopoietic progenitor cells; specific cell depletion within harvest,
T-cell depletion); 38211 (Transplant preparation of hematopoietic
progenitor cells; tumor cell depletion); 38212 (Transplant preparation
of hematopoietic progenitor cells; red blood cell removal); 38213
(Transplant preparation of hematopoietic progenitor cells; platelet
depletion); 38214 (Transplant preparation of hematopoietic progenitor
cells; plasma (volume) depletion); and 38215 (Transplant preparation of
hematopoietic progenitor cells; cell concentration in plasma,
mononuclear, of buffy coat layer). These six CPT codes are currently
assigned to status indicator ``B,'' while HCPCS code G0267 is assigned
to APC 0110 (Transfusion) for payment, with a status indicator of
``S.''
In the CY 2008 OPPS/ASC proposed rule (72 FR 42774), we proposed to
discontinue recognizing HCPCS code G0267, assign it status indicator
``B,'' and recognize the six more specific CPT codes, which we proposed
to assign to APC 0110 with a status indicator of ``S.'' We also
proposed to continue to assign the historical claims data for HCPCS
code G0267 to APC 0110. Historically, under the OPPS, we recognized the
single G-code rather than the CPT codes
[[Page 66822]]
for the individual transplant cell preparation services because we
believed that the services would be uncommonly provided to Medicare
beneficiaries in the outpatient setting and would likely require
similar resources, so that distinguishing among the services would not
be necessary to ensure appropriate OPPS payment. Stakeholders have
brought to our attention that the current hospital resources associated
with the six different bone marrow and stem cell processing procedures
described by these CPT codes may vary widely. While we recognize that
the services currently reported with G0267 under the OPPS are not
common HOPD procedures, the total volume of these procedures has been
increasing over the past several years. Therefore, we stated that we
believe that, by recognizing the six CPT codes for bone marrow and stem
cell processing services, we would obtain more specific claims data for
ratesetting that would enable us to pay more appropriately for these
services in the future. Consistent with our general OPPS practice, we
proposed to assign the newly recognized CPT codes to the clinical APC
that is most appropriate based on historical claims data for the
predecessor HCPCS code until we have more specific hospital resource
data available to assess the specific CPT codes for possible
reassignment.
In addition, in the CY 2008 OPPS/ASC proposed rule (72 FR 42774),
we proposed to discontinue recognition of HCPCS code G0265
(Cryopreservation, freezing and storage of cells for therapeutic use)
and G0266 (Thawing and expansion of frozen cells for therapeutic use),
currently assigned status indicator ``A'' under the OPPS and paid
according to the Medicare Clinical Laboratory Fee Schedule (CLFS), by
assigning them status indicator ``B'' for CY 2008. We proposed to
recognize, instead, CPT codes 38207 (Transplant preparation of
hematopoietic progenitor cells; cryopreservation and storage); 38208
(Transplant preparation of hematopoietic progenitor cells; thawing of
previously frozen harvest, without washing); and 38209 (Transplant
preparation of hematopoietic progenitor cells; thawing of previously
frozen harvest, with washing) for payment under the OPPS. We believed
these services were similar to blood processing services that are
currently paid under the OPPS. We proposed to assign CPT codes 38207
through 38209 to APC 0344 (Level IV Pathology) based on their clinical
characteristics and resource costs from historical hospital claims data
for HCPCS codes G0265 and G0266, which would have been assigned to the
same clinical APC if they were to be paid under the OPPS. Although
HCPCS codes G0265 and G0266 have not historically been paid under the
OPPS, we have a small number of HOPD single claims from CY 2006 for
these two predecessor HCPCS codes (when they were paid off the CLFS),
respectively, and similar laboratory tissue cryopreservation and
thawing services also were proposed for assignment to APC 0344 under
the CY 2008 OPPS. We indicated in the CY 2008 OPPS/ASC proposed rule
that we believe this proposal would allow us to pay appropriately for
all of these bone marrow and stem cell processing services and to
collect more specific hospital resource data.
At the September 2007 meeting of the APC Panel, following a public
presentation regarding these bone marrow and stem cell processing
services, the APC Panel recommended that CMS reevaluate its decision to
place CPT codes 38210, 38211, 38212, 38213, 38214 and 38215 in APC 0110
and also to reevaluate its decision to place CPT codes 38207, 38208,
and 38209 in APC 0344.
We received several public comments on our proposal to recognize
the nine CPT codes for bone marrow and stem cell processing services
under the CY 2008, as well on their proposed APC assignments. A summary
of the comments and our response follows.
Comment: Commenters universally supported the proposal to
discontinue using HCPCS codes G0265, G0266, and G0267) and to recognize
the nine existing CPT codes for bone marrow and stem cell processing
services. Several commenters also urged reconsideration of the proposed
APC assignments of the CPT codes. Some commenters objected to the
placement of CPT codes 38207 through 38209, for cryopreservation and
thawing, in APC 0344 because they believed that the bone marrow and
stem cell cryopreservation and thawing services require much greater
hospital resources than the preparation of laboratory tissue specimens.
Instead, they recommended that CMS place these codes in APC 0111 (Blood
Product Exchange) because the proposed payment rate of approximately
$777 for that APC would pay an average amount for the services as a
whole, paying less than the commenters' estimated costs of freezing and
storing the products based upon their survey data from hospital centers
that perform bone marrow transplantation services and substantially
more than their average estimated cost of thawing the material.
A few commenters also disagreed with the proposed assignments of
CPT codes 38210 through 38215 to APC 0110. They argued that the APC is
populated mainly by transfusion procedures that do not resemble the
bone marrow and stem cell depletion services either from the clinical
or hospital resource perspective. The commenters also believed that, of
the few single claims for G0267 that were available for ratesetting,
most of those claims were for the lower cost depletion services instead
of the much more uncommon and costly services reported with CPT codes
38210, for T-cell depletion, and 38211, for tumor cell depletion. Based
on external cost data they collected from hospital transplant centers
performing specialized bone marrow and stem cell processing services,
the commenters presented two options for CPT codes 38210 and 38211: (1)
Place them in APC 0112 (Apheresis and Stem Cell procedures); or (2) pay
for them based on the hospital's charges adjusted to cost using the
hospital's overall CCR, similar to the payment methodology for pass-
through devices. The commenters recommended that the remaining CPT
codes, 38212 through 38215, be placed in a separate APC as an interim
step, using the median cost data for the predecessor HCPCS code G0267
to establish the APC payment rate.
Response: We appreciate the support of commenters and the APC Panel
for our proposal to discontinue use of the three G-codes currently used
to report bone marrow and stem cell processing services and recognize
CPT codes 38207 through 38215 instead. We agree with the commenters
that using the most specific CPT codes for reporting these bone marrow
and stem cell processing services would reduce the administrative
reporting burden for hospitals and provide more specific claims-based
costs for future ratesetting. We also accept the APC Panel's
recommendations to reconsider our proposed placements of these bone
marrow and stem cell processing codes. We have reviewed available
claims data in view of the comments, as discussed below.
After reviewing our claims data available for this final rule with
comment period, we agree with the commenters that, in order to ensure
clinical and resource homogeneity, it would be preferable to group CPT
codes 38207 through 38209 for cryopreservation, thawing, and washing
procedures with other services that involve the handling of blood
products, rather than to APC 0344, where most procedures involve the
processing of
[[Page 66823]]
tissue specimens for laboratory analysis. However, we disagree with the
commenters that APC 0111, with a median cost of approximately $724 for
apheresis and autologous progenitor cell harvesting services, is an
appropriate assignment. We do not believe that CPT codes 38207 through
38209 are clinically similar to apheresis services. We note that the
limited claims data we have for the predecessor codes, specifically
HCPCS codes G0265 and G0266, reveal median costs of approximately $118
and $244 based on 23 and 548 single claims, respectively. Even though
these services were previously paid in the HOPD through the CLFS, CY
2006 claims data are available for OPPS ratesetting. Instead, we
believe that CPT codes 38207 through 38209 should be assigned, along
with other procedures involving blood products, to APC 0110 with a
status indicator of ``S'' and an APC median cost of approximately $214.
This is consistent with the historical hospital costs for the
cryopreservation and thawing services as reported under the G-codes.
Additionally, we are assigning CPT codes 38210 through 38215,
reported for bone marrow and stem cell depletion services, to APC 0393
with other services that involve red blood cells and plasma. We are
renaming APC 0393 ``Hematologic Processing and Studies'' so that the
title more accurately describes all the services assigned to the APC.
We are maintaining a status indicator of ``S.'' for APC 0393. The
median cost of APC 0393 is approximately $358, the same median cost as
HCPCS code G0267, the predecessor code recognized under the OPPS. We
agree with the commenters that, based on our proposed assignment of the
depletion services to APC 0110 according to the data for their
predecessor code, while there was no violation of the 2 times rule,
HCPCS code G0267 had a high median cost compared to the proposed median
cost of approximately $220 for that APC. Our reassignment of CPT codes
38210 through 38215 to APC 0393 will pay appropriately for these CPT
codes while we collect more specific data on their individual resource
costs.
We do not agree with the commenters that the two specific services
for T-cell or tumor depletion, which that they believe are particularly
costly, would be appropriately paid through APC 0112, which contains
procedures for extracorporeal adsorption of cells during apheresis and
reinfusion into the patient. Furthermore, we believe that a cost-based
methodology for payment of these procedures would not be consistent
with the principles of a prospective payment system that provides
prospectively established payment for services. The cost-based payment
methodology is statutorily required for payment of pass-through
devices. As we stated in the proposed rule, it is consistent with our
general practice under the OPPS to make payment based on historical
claims data for the predecessor HCPCS code until we have more specific
hospital resource data available to assess the specific CPT codes for
possible reassignment.
After consideration of the public comments received and the
recommendations of the APC Panel, we are finalizing our proposal,
without modification, to discontinue use of HCPCS codes G0265, G0266,
and G0267 and recognize CPT codes 38207 through 38215 to report bone
marrow and stem cell processing services under the OPPS. However, we
are not finalizing the APC assignments of these services as proposed.
Instead, we are assigning CPT codes 38207, 38208 and 38209 for
cryopreserving, thawing and washing bone marrow and stem cells to APC
0110, with a median cost of approximately $214 and a status indicator
of ``S.'' In addition, we are assigning CPT codes 38210 through 38215,
reported for depletion services of bone marrow and stem cells, to APC
0393, which is renamed ``Hematologic Processing and Studies,'' with a
median cost of approximately $358 and a status indicator of ``S.''
G. Reporting of Alcohol and/or Substance Abuse Assessment and
Intervention Services
For CY 2008, the CPT Editorial Panel has created two new Category I
CPT codes for reporting alcohol and/or substance abuse screening. They
are CPT code 99408 (Alcohol and/or substance (other than tobacco) abuse
structured screening (e.g., AUDIT, DAST), and brief intervention (SBI)
services; 15 to 30 minutes); and CPT code 99409 (Alcohol and/or
substance (other than tobacco) abuse structured screening (e.g., AUDIT,
DAST), and brief intervention (SBI) services; greater than 30 minutes).
The code descriptions for these CPT codes suggest that these CPT
codes may describe services that include screening services. For
Medicare purposes, screening services are typically considered to be
provided to beneficiaries in the absence of signs or symptoms of
illness or injury; therefore, to the extent that services described by
these two CPT codes have a screening element, the screening component
would not meet the statutory requirements for coverage under section
1862(a)(1)(A) of the Act. Screening services are not covered by
Medicare without specific statutory authority, such as has been
provided for mammography, diabetes, and colorectal cancer screening.
Accordingly, we will not recognize these CPT codes that incorporate
screening for payment under the OPPS.
Therefore, for CY 2008, we have created two parallel G-codes to
allow for appropriate Medicare reporting and payment for alcohol and
substance abuse assessment and intervention services that are not
provided as screening services, but that are performed in the context
of the diagnosis or treatment of illness or injury. The codes are HCPCS
code G0396 (Alcohol and/or substance (other than tobacco) abuse
structured assessment (e.g., AUDIT, DAST) and brief intervention, 15 to
30 minutes); and HCPCS code G0397 (Alcohol and/or substance (other than
tobacco) abuse structured assessment (e.g,. AUDIT, DAST) and
intervention, greater than 30 minutes). We will instruct Medicare
contractors to pay for these codes only when considered reasonable and
necessary. We will also provide coding and payment instructions for
these assessment and intervention services in the program instructions
implementing the January 2008 OPPS update.
CPT codes 99408 and 99409 are assigned status indicator ``E'' for
CY 2008 on an interim final basis under the OPPS, meaning that they
will not be recognized for payment under the OPPS or any other Medicare
payment system. HCPCS codes G0396 and G0397 are assigned status
indicator ``S.'' They are assigned, on an interim final basis, with
other health and behavioral assessment and intervention services to APC
0432 (Health and Behavioral Services). We believe that HCPCS codes
G0396 and G0397 share significant clinical and resources
characteristics with other services also assigned to APC 0432 for CY
2008, thereby ensuring the clinical and resource homogeneity of the
APC. The final CY 2008 median cost of APC 0432 is approximately $20.
Because these CPT and Level II HCPCS codes were not available for the
CY 2008 OPPS/ASC proposed rule, we have flagged them with comment
indicator ``NI'' in Addendum B of this OPPS final rule with comment
period to signify that their interim payment status is subject to
public comment following publication of the final rule that implements
the annual OPPS update.
[[Page 66824]]
XIV. OPPS Payment Status and Comment Indicators
A. Payment 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 final CY
2008 status indicator assignments for APCs and HCPCS codes are shown in
Addendum A and Addendum B, respectively, to this final rule with
comment period. As we proposed in the CY 2008 OPPS/ASC proposed rule,
in this final rule with comment period 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
------------------------------------------------------------------------
Indicator Item/code/service OPPS payment status
------------------------------------------------------------------------
G................... Pass-Through Drugs and (1) Paid under OPPS;
Biologicals. separate APC payment.
H................... Pass-Through Device Separate cost-based pass-
Categories. through payment; not
subject to copayment.
K................... (1) Non-Pass-Through (1) Paid under OPPS;
Drugs and Biologicals. separate APC payment.
(2) Therapeutic (2) Paid under OPPS;
Radiopharmaceuticals. separate APC payment.
(3) Brachytherapy (3) Paid under OPPS;
Sources. separate APC payment.
(4) Blood and Blood (4) Paid under OPPS;
Products. separate APC payment.
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.
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.
X................... Ancillary Services...... Paid under OPPS;
separate APC payment.
------------------------------------------------------------------------
As discussed in section VII.A. of the proposed rule and this final
rule with comment period, subsequent to the publication of the CY 2007
OPPS/ASC final rule with comment period, section 107(a) of the MIEA-
TRHCA extended the payment period for brachytherapy sources paid under
the OPPS based on a hospital's charges adjusted to cost under section
1833(t)(16)(C) of the Act for one additional year. This requirement for
cost-based payment ends after December 31, 2007. Therefore, we
continued the OPPS cost-based payment for brachytherapy sources through
CY 2007, and are using status indicator ``H'' during CY 2007 to
designate non-pass-through brachytherapy sources paid on a cost basis.
However, as discussed in detail in section VII.A. of this final
rule with comment period, we are implementing prospective payment for
brachytherapy sources paid under the OPPS in CY 2008. In accordance
with this final policy, as proposed we also are discontinuing our use
of payment status indicator ``H'' for APCs assigned to brachytherapy
sources. As indicated in section VII.A. of this final rule with comment
period, for CY 2008 we are using payment status indicator ``K'' to
designate all brachytherapy source APCs that will be paid under the
OPPS.
As discussed in detail in section V.B.3.a.(4)(c) of this final rule
with comment period, we are implementing prospective payment for
therapeutic radiopharmaceuticals separately paid under the OPPS in CY
2008. In accordance with this final policy, as proposed, we also are
discontinuing our use of payment status indicator ``H'' for APCs
assigned to therapeutic radiopharmaceuticals. Similar to the
identification of other non-pass-through drugs and biologicals, for CY
2008, we are using payment status indicator ``K'' to designate all
therapeutic radiopharmaceutical APCs that will be paid under the OPPS.
We received several public comments regarding the appropriateness
of the status indicator assignments for specific HCPCS codes that are
discussed in the sections of this final rule with comment period that
are specific to those topics. There were also recommendations about
specific payment policies for certain items and services and
recommended status indicators that are discussed elsewhere in this
final rule with comment period.
Comment: One commenter believed that composite APCs differ
significantly from the conditional packaging methodology for special
packaged codes, where CMS provides a payment for a service only if
there is no other service on the claim for the same date with status
indicator ``X,'' ``V,'' ``S,'' or ``T.'' The commenter believed that
CMS should assign a status indicator other than ``Q'' to services that
may be subject to a composite APC methodology, where the service would
be paid through the composite APC payment for two or more services on
the same date.
Response: We appreciate the commenter's interest in refining the
use of status indicator ``Q'' under the OPPS. However, we are adopting
our proposal, without modification, to identify HCPCS codes that are
members of composite APCs with status indicator ``Q'' for CY 2008,
because we believe the definition of this status indicator
appropriately describes the payment policy for these codes as well as
special packaged codes, specifically that separate payment is only made
if certain criteria are met. As we continue to explore the
possibilities of greater packaging and encounter- and episode-based
payment under the OPPS, we will consider how to further refine the OPPS
status indicators to provide the most relevant information concerning
payment of OPPS services.
After considering the public comments received concerning the
proposed use of status indicators for services that are paid under the
OPPS, we are adopting as final, without
[[Page 66825]]
modification, the status indicators for payable OPPS services for CY
2008 as displayed in the table above.
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 to a Not paid under OPPS.
hospital outpatient Paid by fiscal
that are paid under a intermediaries/MACs
fee schedule or payment under a fee schedule or
system other than OPPS, payment system other
for example: than OPPS.
Ambulance
Services.
Clinical Not subject to
Diagnostic deductible or
Laboratory Services. coinsurance.
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 Not subject to
Mammography. deductible.
C................... Inpatient Procedures.... Not paid under OPPS.
Admit patient. Bill as
inpatient.
F................... Corneal Tissue Not paid under OPPS.
Acquisition; Certain Paid at reasonable
CRNA Services; and cost.
Hepatitis B Vaccines.
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/MAC.
Y................... Non-Implantable Durable Not paid under OPPS. All
Medical Equipment. institutional providers
other than home health
agencies bill to DMERC.
------------------------------------------------------------------------
We did not receive any public comments regarding the status
indicators to designate services paid under a payment system other than
the OPPS. Therefore, we are finalizing our CY 2008 proposal, without
modification. The final status indicators are displayed in the table
above.
3. Payment Status Indicators To Designate Services That Are Not
Recognized Under the OPPS But That May Be Recognized by Other
Institutional Providers
------------------------------------------------------------------------
Indicator Item/code/service OPPS payment status
------------------------------------------------------------------------
B................... Codes that are not Not paid under OPPS.
recognized by OPPS when
submitted on an
outpatient hospital
Part B bill type (12x
and13x).
May be paid by
intermediaries/MACs
when submitted on a
different bill type,
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.
------------------------------------------------------------------------
We did not receive any public comments regarding the status
indicators to designate services that are not recognized under the OPPS
but that may be recognized by other institutional providers. Therefore,
we are finalizing our CY 2008 proposal, without modification. The final
status indicators are displayed in the table above.
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 or
Services: any other Medicare
payment system.
That are not
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.
------------------------------------------------------------------------
[[Page 66826]]
We did not receive any public comments regarding the status
indicators to designate services that are not payable by Medicare.
Therefore, we are finalizing our CY 2008 proposal, without
modification. The final status indicators are displayed in the table
above.
To address providers' broader interests and to make the published
Addendum B more convenient for public use, we are displaying in
Addendum B to this final rule with comment period all active HCPCS
codes for CY 2008 and currently active HCPCS codes that will be
discontinued at the end of CY 2007 that describe items or services that
are: (1) Payable under the OPPS; (2) paid under a payment system other
than the OPPS; (3) not recognized under the OPPS but that may be
recognized by other institutional providers; and (4) not payable by
Medicare. The universe of CY 2008 status indicators that we proposed
for these items and services and are adopting as final without
modification in this final rule with comment period are listed in the
tables above.
A complete listing of HCPCS codes with payment status indicators
and APC assignments for CY 2008 is also available electronically on the
CMS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/
list.asp#TopOfPage.
B. 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 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.
In the November 10, 2005 final rule with comment period (70 FR
68702 and 68703), we adopted a new comment indicator:
``CH''--Active HCPCS codes in current and next calendar
year; status indicator and/or APC assignment have changed or active
HCPCS code that will be 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.
In the CY 2008 OPPS/ASC proposed rule, for CY 2008, we proposed to
continue that policy which we are now adopting in this CY 2008 OPPS/ASC
final rule with comment period. When used in this OPPS/ASC final rule
with comment period, the ``CH'' indicator is only intended to
facilitate the public's review of changes made from one calendar year
to another.
Only HCPCS codes with comment indicator ``NI'' in this CY 2008
OPPS/ASC final rule with comment period are subject to comment during
the comment period for this final rule with comment period.
We are using the ``CH'' indicator in this final rule with comment
period to call attention to changes in the payment status indicator
and/or APC assignment for HCPCS codes for CY 2008 compared to their
assignment as of December 31, 2007 and to identify HCPCS codes that
will be discontinued at the end of CY 2007. The use of the comment
indicator ``CH'' in association with a composite APC in this final rule
with comment period indicates that the configuration of the composite
APC is changed from CY 2007. We believe that using the ``CH'' indicator
in this final rule with comment period will facilitate the public's
review of the changes that we are making final for CY 2008.
As we proposed, we are terminating comment indicator ``NF'' because
we believe its use is not relevant in the final rule.
We did not receive any public comments regarding the CY 2008
proposed OPPS comment indicators. Therefore, we are finalizing our
proposed use of comment indicators for the CY 2008 OPPS/ASC final rule
with comment period, without modification. The two comment indicators,
``NI'' and ``CH,'' that are finalized for continued use in CY 2008 and
their definitions are listed in Addendum D2 to this final rule with
comment period.
XV. OPPS Policy and Payment Recommendations
A. MedPAC Recommendations
MedPAC is an independent Federal commission established under
section 1805 of the Act to advise the U.S. Congress on issues affecting
the Medicare program. As required under the statute, MedPAC submits
reports to Congress in March and June of each year that present its
payment policy recommendations. The March 2007 MedPAC report, ``Report
to the Congress: Medicare Payment Policy,'' included the following
recommendation relating specifically to the hospital OPPS:
Recommendation 2A-1: The Congress should increase payment rates for
the * * * outpatient prospective payment system in 2008 by the
projected rate-of-increase in the hospital market basket index,
concurrent with the implementation of a quality incentive payment
program.
CMS Response: As proposed in the CY 2008 OPPS/ASC proposed rule, in
this final rule with comment period, we are increasing the payment
rates for the CY 2008 OPPS by the projected rate-of-increase in the
hospital market basket index (as discussed in section II.C. of this
final rule with comment period). We are also implementing, effective
for CY 2009, the reduction in the annual update factor by 2.0
percentage points for hospitals that are defined under section
1886(d)(1)(B) of the Act and that do not meet the hospital outpatient
quality data reporting required by section 1833(t)(17) of the Act, as
added by section 109(a) of the MIEA-TRHCA. Our adoption and
implementation of hospital quality measure reporting for the CY 2008
OPPS are discussed in detail in section XVII. of this final rule with
comment period.
In its June 2007 ``Report to the Congress: Promoting Greater
Efficiency in Medicare,'' MedPAC did not make any recommendations
specific to the OPPS for CY 2008. As noted in the FY 2008 IPPS final
rule with comment period (72 FR 47344), the June 2007 MedPAC report
includes analysis and recommendations on alternatives to the method to
compute the IPPS wage index for FY 2009. (See chapter 6 of the June
2007 MedPAC report to Congress.) Under our current policy, we adopt the
same wage index for the OPPS as the IPPS, and, therefore, such analysis
and recommendations may have possible implications for the CY 2009
OPPS. As indicated in the FY 2008 IPPS final rule with comment period
(72 FR 47344), we will consider MedPAC's recommendations and analysis
in making a proposal (or proposals) to revise the IPPS wage index in
the FY 2009 IPPS proposed rule, as required by section 106(b)(2) of the
MIEA-TRHCA. The full report can be downloaded from MedPAC's Web site
at: http://www.medpac.gov/document/Jun07_EntireReport.pdf.
[[Page 66827]]
MedPAC submitted comments to CMS on the CY 2008 OPPS/ASC proposed
rule. We have responded to these comments in each relevant section of
this final rule with comment period.
B. APC Panel Recommendations
Recommendations made by the APC Panel at its March 2007 meeting are
discussed in sections of this final rule with comment period that
correspond to topics addressed by the APC Panel. The report and
recommendations from the APC Panel's March 7-8, 2007 meeting are
available on the CMS Web site at: http://www.cms.hhs.gov/FACA/05--
AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp.
Recommendations made by the APC Panel at its September 2007
meeting, when it met to discuss the CY 2008 OPPS/ASC proposed rule and
to hear testimony from concerned members of the public, are also
discussed in sections of this final rule with comment period that
correspond to topics addressed by the APC Panel. The report and
recommendations of the APC Panel's September 5-6, 2007 meeting are also
available on the CMS Web site at: http://www.cms.hhs.gov/FACA/05--
AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp.
XVI. Update of the Revised Ambulatory Surgical Center Payment System
A. Legislative and Regulatory Authority for the ASC Payment System
Section 1832(a)(2)(F)(i) of the Act provides that benefits under
the Medicare Part B include payment for facility services furnished in
connection with surgical procedures specified by the Secretary that are
performed in an 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, which are implemented in 42 CFR part 416,
subpart B and subpart C of our regulations. The regulations at 42 CFR
416, subpart B set forth general conditions and requirements for ASCs,
and the regulations at subpart C provide specific conditions for
coverage for ASCs.
To establish the reasonable estimated allowances for ASC facility
services, section 1833(i)(2)(A)(i) of the Act required us to take into
account the audited costs incurred by ASCs to perform a procedure, in
accordance with a survey. 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 141(b) of the Social Security Act Amendments of 1994, Pub.
L. 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) that belong
to a class of new technology intraocular lenses (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 on June 16, 1999, in the
Federal Register (64 FR 32198).
Section 626(b) of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003, Pub. L. 108-173, (MMA) 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 required the Secretary to implement a revised ASC
payment system, to be effective not later than January 1, 2008.
Section 626(c) of the MMA amended section 1833(a)(1) of the Act to
require that beginning with implementation of the revised ASC payment
system, payment for surgical procedures furnished in ASCs shall be 80
percent of the lesser of the actual charge for the services or the
amount determined by the Secretary under the revised payment system.
Section 5103 of the Deficit Reduction Act of 2005, Pub. L. 109-171
(DRA), 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. The amended language provides that if the standard
overhead amount under section 1833(i)(2)(A) of the Act for an ASC
facility service for such surgical procedures, without application of
any geographic adjustment, exceeds the Medicare payment amount under
the hospital OPPS 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
(that is, January 1, 2008).
Section 109(b) of the Medicare Improvements and Extension Act of
2006 of the Tax Relief and Health Care Act of 2006, Pub. L. 109-432
(MIEA-TRHCA), amended section 1833(i) of the Act, in part, by adding
new clause (iv) to paragraph (2)(D) and by also adding new paragraph
(7)(A), which provides that the Secretary may reduce the annual ASC
update by 2 percentage points if an ASC fails to submit data as
required by the Secretary on selected measures of quality of care,
including medication errors. Section 109(b) of the MIEA-TRCHA requires
that certain quality of care reporting requirements mandated for
hospitals paid under the OPPS by section 109(a) of the MIEA-TRCHA be
applied in a similar manner to ASCs unless otherwise specified by the
Secretary. We refer readers to sections XVII.A. and H. of this final
rule with comment period for further discussion of this provision and
our plans for future ASC implementation.
B. Rulemaking for the Revised ASC Payment System
On August 2, 2007, we published in the Federal Register (72 FR
42470) the final rule for the revised ASC payment system, effective
January 1, 2008. In that final rule, we established that we would
address two components of the ASC payment system annually as part of
the OPPS rulemaking cycle. 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, CAH, or
an HOPD and to review and update the list of ASC procedures at least
every 2 years.
In the August 2, 2007 revised ASC payment system final rule, we
also adopted the method we will use to set payment rates for ASC
services furnished in association with covered surgical procedures
beginning in CY 2008. Updating covered surgical procedures and covered
ancillary services, as well as their payment rates, in association with
the annual OPPS rulemaking cycle is particularly important because the
OPPS relative payment weights and rates will be used as the basis for
the payment of most covered surgical procedures and covered ancillary
services under the revised ASC payment system. This joint update
process will ensure that the ASC updates occur in a regular,
predictable, and timely manner. The final rule included applicable
regulatory changes to 42 CFR Parts 410 and 416.
On August 2, 2007, we published in the Federal Register (72 FR
42778) a proposed rule which proposed to update the revised ASC payment
system, along with the OPPS. We also proposed to revise the ASC
regulations to provide practice expense payments to physicians who
perform noncovered ASC procedures in ASCs based on the
[[Page 66828]]
facility practice expense (PE) relative value units (RVUs) and to
exclude covered ancillary radiology services and covered ancillary
drugs and biologicals from the categories of designated health services
(DHS) that are subject to the physician self-referral prohibition. We
note that the reference throughout the August 2, 2007 OPPS/ASC proposed
rule to the final rule for the CY 2008 revised ASC payment system
erroneously cited that final rule as the July 2007 final rule.
In this CY 2008 OPPS/ASC final rule with comment period, we are
performing our annual update of the revised ASC payment system for CY
2008.
C. Revisions to the ASC Payment System Effective January 1, 2008
1. Covered Surgical Procedures Under the Revised ASC Payment System
a. Definition of Surgical Procedure
In order to delineate the scope of procedures that constitute
``outpatient surgical procedures'' for payment under the revised ASC
payment system, in the August 2, 2007 revised ASC payment system final
rule, we clarified what we consider to be a ``surgical'' procedure.
Under the ASC payment system existing through CY 2007, we define a
surgical procedure as any procedure described within the range of
Category I CPT codes that the CPT Editorial Panel of the AMA defines as
``surgery'' (CPT codes 10000 through 69999). Under the revised payment
system, we continue to define ``surgery'' using that standard. We also
include within the scope of surgical procedures payable in an ASC those
procedures that are described by Level II HCPCS codes or by Category
III CPT codes that directly crosswalk or are clinically similar to
procedures in the CPT surgical range that we have determined do not
pose a significant safety risk and that we would not expect to require
an overnight stay when performed in an ASC. Having established what we
consider to be a ``surgical procedure,'' we defined criteria that
enable us to identify procedures that could pose a significant safety
risk when performed in an ASC or that we expect would require an
overnight stay within the bounds of prevailing medical practice.
b. Identification of Surgical Procedures Eligible for Payment under the
Revised ASC Payment System
ASC ``covered surgical procedures'' are those surgical procedures
for which payment is made under the revised ASC payment system. Our
final policy for identifying surgical procedures eligible for ASC
payment excludes those surgical procedures that are on the OPPS
inpatient list, procedures that are packaged under the OPPS, CPT
unlisted surgical procedure codes, and surgical procedures that are not
recognized for payment under the OPPS. Further, we exclude from ASC
payment any procedure for which standard medical practice dictates that
the beneficiary would typically be expected to require active medical
monitoring and care at midnight following the procedure (overnight
stay), and all surgical procedures that could pose a significant safety
risk to Medicare beneficiaries. The criteria used under the revised ASC
payment system to identify procedures that could pose a significant
safety risk when performed in an ASC include those procedures that:
Generally result in extensive blood loss; require major or prolonged
invasion of body cavities; directly involve major blood vessels; are
emergent or life-threatening in nature; or commonly require systemic
thrombolytic therapy. These criteria for evaluating surgical procedures
are set forth in Sec. 416.166(c).
The list of surgical procedures that we have excluded from payment
in ASCs may be found in Addendum EE posted on the CMS Web site at:
http://www.cms.hhs./ASCPayment. As discussed above, the surgical
procedures on that exclusionary list are those that are on the OPPS
inpatient list, CPT unlisted codes, surgical procedures that are not
recognized for payment under Medicare, and those that our clinical
staff determined are not safe for Medicare beneficiaries or would be
expected to require an overnight stay when provided in ASCs.
c. Payment for Covered Surgical Procedures under the Revised ASC
Payment System
(1) General Policies
To make payment for most covered surgical procedures, beginning in
CY 2008, we utilize the OPPS APCs as a ``grouper'' and the APC relative
payment weights as the basis for ASC relative payment weights and for
calculating ASC payment rates under the revised payment system, by
applying a uniform ASC conversion factor to the ASC payment weights.
For this first year of the revised ASC payment system, we adopted the
OPPS relative payment weights as the ASC relative payment weights for
most covered surgical procedures.
For CY 2009 and beyond, according to our established methodology,
we will update the ASC relative payment weights annually using the OPPS
relative payment weights for that calendar year, as well as the
practice expense payment amounts under the MPFS schedule for that
calendar year, because some covered office-based surgical procedures
and covered ancillary services will be paid according to MPFS amounts
if those amounts are less than the rates calculated under the standard
methodology of the revised ASC payment system.
Just as we scale the OPPS relative payment weights each year to
ensure that the OPPS is budget neutral from one year to the next, we
will rescale relative weights each year for the revised ASC payment
system, beginning with the CY 2009 payment year. The purpose of scaling
the relative weights is to ensure that the estimated aggregate payments
under the ASC payment system for an upcoming year will be neither
greater than nor less than the aggregate payments that would be made in
the prior year, taking into consideration any changes or recalibrations
for the upcoming year. Rescaling enables us to compensate for the
effects of changes in the OPPS relative payment weights from year to
year for services that are not performed in ASCs (for example, due to
sudden increases or decreases in the costs of hospital outpatient
emergency department visits) that could inappropriately cause the
estimated ASC expenditures to increase or decrease as a function of
those changes.
To establish the budget neutrality adjustment for the revised ASC
payment system, we used a model that accounts for the migration of
surgical procedures between ASCs, physicians' offices, and HOPDs, as
discussed in the August 2, 2007 revised ASC payment system final rule
(72 FR 42470). The budget neutrality adjustment for CY 2008 is based on
updated CY 2008 OPPS and MPFS rates, along with updated utilization
data. The ASC CY 2008 budget neutrality adjustment is multiplied by the
OPPS conversion factor to establish the ASC conversion factor. The
standard ASC payment for most of the covered surgical procedures
displayed in Addendum AA of this final rule with comment period is
calculated as the product of that ASC conversion factor multiplied by
the OPPS relative payment weight for each separately payable procedure.
A more detailed discussion of the methodology is provided in section
XVI.L. of this final rule with comment period.
Beginning in CY 2010, we will update the ASC conversion factor for
the revised ASC payment system by the percentage increase in the CPI-U
(U.S. city average), as estimated for the 12-
[[Page 66829]]
month period ending with the midpoint of the year involved (72 FR
42519).
(2) Office-Based Procedures
Among the procedures newly identified as covered surgical
procedures for payment in ASCs beginning in CY 2008 are many procedures
that are performed most of the time in physicians' offices. These
procedures neither pose a significant safety risk nor are they expected
to require an overnight stay when performed in ASCs, and they generally
require a lower level of resource intensity than do most other ASC
covered surgical procedures. For those reasons, in the August 2, 2007
revised ASC payment system final rule, we adopted a policy to include
them as covered surgical procedures but to ensure that payment for the
facility resources associated with the procedures identified as
``office-based'' would not be greater when provided in ASCs than when
furnished in physicians' offices (72 FR 42509).
Under the August 2, 2007 revised ASC payment system final rule, we
finalized our policy to cap payment for office-based surgical
procedures for which ASC payment would first be allowed beginning in CY
2008 or later years at the lesser of the MPFS nonfacility PE RVU amount
or the ASC rate developed according to the standard methodology of the
revised ASC payment system. For those office-based procedures for which
there is no available MPFS nonfacility PE RVU amount, we will implement
the cap, as appropriate, once a MPFS nonfacility PE RVU amount is
available. When procedures are finalized as being office based
procedures, they remain designated as office-based in future updates.
We may propose that additional HCPCS codes be classified as office-
based in a proposed rule for an annual ASC update after review of the
most recently available utilization data. We consider for additional
designation as office-based those procedures newly paid in ASCs in CY
2008 or later years that our review concludes are performed
predominantly (more than 50 percent of the time) in physicians'
offices, based on our consideration of volume and site of service
utilization data for the procedures, as well as clinical information
and comparable data for related procedures, if appropriate.
Procedures designated as office-based for CY 2008 are identified in
Addendum AA to this final rule with comment period and assigned payment
indicators ``P2'' (Office-based surgical procedures added to ASC list
in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on
OPPS relative payment weight); ``P3'' (Office based surgical procedure
added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs;
payment based on MPFS nonfacility PE RVUs); and ``R2'' (Office-based
surgical procedure added to ASC list in CY 2008 or later without MPFS
nonfacility PE RVUs; payment based on OPPS relative payment weight).
Those procedures for which the payment indicator designation as office-
based is temporary for CY 2008 are identified in Addendum AA by an
asterisk. We use the temporary designation to indicate that the office-
based payment indicator (``P2,'' ``P3,'' or ``R2'') assigned to the
procedure is subject to change because the HCPCS code is new and we
believe we have insufficient data upon which to base a final decision
regarding the code's office-based status. We will reevaluate the
procedure during the next annual rulemaking cycle, and when there are
data upon which to base a proposal for a final payment indicator, we
will include that in our proposed rule. The remainder of the office-
based procedure designations that are not identified as temporary were
either already finalized in the August 2, 2007 revised ASC payment
system final rule or are being finalized in this CY 2008 OPPS/ASC final
rule with comment period.
(3) Device-Intensive Procedures
Under the payment policy finalized in the revised ASC payment
system final rule, we use a modified payment methodology to establish
the ASC payment rates for device-intensive procedures (72 FR 42503). We
identify device-intensive procedures under the revised ASC payment
system as covered surgical procedures that, under the OPPS, are
assigned to those device-dependent APCs for which the ``device offset
percentage'' is greater than 50 percent of the APC's median cost. The
device offset percentage is our best estimate of the percentage of
device cost that is included in an APC payment under the OPPS. The CY
2008 OPPS final device-dependent APCs and device offset percentages are
discussed in section IV.A. of this final rule with comment period.
According to the final ASC policy, payment for implantable devices
is packaged into payment for the covered surgical procedures, but we
utilize a modified ASC methodology based on OPPS data to establish
payment rates for the device-intensive procedures under the revised ASC
payment system. According to that modified payment methodology, we
apply the OPPS device offset percentage to the OPPS national unadjusted
payment to determine the device cost included in the OPPS payment rate
for a device-intensive ASC covered surgical procedure, which we then
set as equal to the device portion of the national unadjusted ASC
payment rate for the procedure. We then calculate the service portion
of the ASC payment for device-intensive procedures by applying the
uniform ASC conversion factor to the service (nondevice) portion of the
OPPS relative payment weight for the device-intensive procedure.
Finally, we sum the ASC device portion and ASC service portion to
establish the full payment for the device intensive procedure under the
revised ASC payment system. For example, if the OPPS device offset
percentage for the procedure is 80 percent and the OPPS national
unadjusted payment is $100, the device cost included in that payment is
$80. Under the revised ASC payment system, we also pay $80 for the
device portion of the procedure but the service portion of the OPPS
payment, $20, is adjusted by the budget neutrality adjustment (for
example, using the final ASC budget neutrality adjustment, the
calculation is $20 x 0.65 = $13) and, if it is subject to the
transition (as set forth in section XVI.C.1.c.(5) of this final rule
with comment period), it is also adjusted accordingly. If the procedure
in the example is not subject to the transition, its CY 2008 payment is
equal to approximately $93 ($80 + $13). This example illustrates the
contributions of the device and service payment amounts to the national
unadjusted ASC payment rate; payment to an ASC for the device-intensive
service is subject to the 50 percent geographic adjustment.
We also reduce the amount of payment made to ASCs for device-
intensive procedures assigned to certain OPPS APCs in those cases in
which the necessary device is furnished without cost to the ASC or the
beneficiary, or with a full credit for the cost of the device being
replaced. A full discussion of that policy may be found in section
XVI.F. of this final rule with comment period.
(4) Multiple and Interrupted Procedure Discounting
Under the revised ASC payment system, we discount payment for
certain multiple and interrupted procedures performed in ASCs. While
most covered surgical procedures are subject to a 50 percent reduction
in ASC payment for the lower-paying procedure when more than one
procedure is performed in a single operative session, those covered
surgical procedures that are exempt from the multiple procedure
reduction
[[Page 66830]]
in ASCs because they are not subject to this reduction under the OPPS,
are identified in Addendum AA to this final rule with comment period
with an ``N'' in the column labeled ``Subject to multiple procedure
discounting.'' Procedures requiring anesthesia that are terminated
after the patient has been prepared for surgery and taken to the
operating room but before the administration of anesthesia are reported
with modifier 73, and the ASC payment for the covered surgical
procedure is reduced by 50 percent. Procedures requiring anesthesia
that are terminated after administration of anesthesia or initiation of
the procedure are reported with modifier 74, and the ASC payment for
the covered surgical procedure is made at 100 percent of the
established payment rate. Procedures and services not requiring
anesthesia that are partially reduced or discontinued at the
physician's discretion are reported with modifier 52, and the ASC
payment for the covered surgical procedure or covered ancillary service
is reduced by 50 percent.
(5) Transition to Revised ASC Payment Rates
Under the revised ASC payment system, we are providing a payment
transition over 4 years for all services on the CY 2007 ASC list of
covered surgical procedures (72 FR 42519). Beginning in CY 2008, the
contribution of CY 2007 ASC payment rates to the blended transitional
rates will decrease by 25 percentage point increments each year of
transitional payment, until CY 2011, when we will fully implement the
revised ASC payment rates calculated under the final methodology of the
revised payment system. While we do not subject the device payment
portion of the total ASC payment for a device-intensive procedure to
the transition policy, we transition the service payment portion of the
total ASC payment for the procedure over the 4 year phase-in period.
Procedures new to ASC payment for CY 2008 or later calendar years
receive payments determined according to the final methodology of the
revised ASC payment system, without a transition.
ASC covered surgical procedures listed in Addendum AA to this final
rule with comment period that are subject to the transition are
assigned payment indicators ``A2'' (Surgical procedure on ASC list in
CY 2007; payment based on OPPS relative payment weight) and ``H8''
(Device-intensive procedure on ASC list in CY 2007; paid at adjusted
rate). ASC covered surgical procedures listed in Addendum AA to this
final rule with comment period that are not subject to the transition
are assigned payment indicators ``G2'' (Nonoffice-based surgical
procedure added to ASC list in CY 2008 or later; payment based on OPPS
relative payment weight); ``J8'' (Device-intensive procedure added to
ASC list in CY 2008 or later; paid at adjusted rate); ``P2'' (Office-
based surgical procedure added to ASC list in CY 2008 or later with
MPFS nonfacility PE RVUs; payment based on OPPS relative payment
weight); ``P3'' (Office-based surgical procedure added to ASC list in
CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS
nonfacility PE RVUs); and ``R2'' (Office-based surgical procedure added
to ASC list in CY 2008 or later without MPFS nonfacility PE RVUs;
payment based on OPPS relative payment weight).
We received many public comments on the final payment policies for
covered surgical procedures under the revised ASC payment system. A
summary of the public comments and our responses follow.
Comment: A number of commenters suggested that CMS: (1) Alter the
definition for surgical procedures and the criteria for evaluating
procedures for exclusion from the list of covered procedures; (2) not
implement the office-based designations for procedures; (3) use a lower
threshold to designate which procedures are eligible for payment as
device-intensive; (4) allow procedures with high supply costs to go to
fully implemented revised payment system rates rather than being paid
at the transitional rates during the first 3 years under the revised
system; and (5) use either a higher budget neutrality adjustment or
differential adjustments for high and low volume procedures. Within
those topics, the commenters made a range of recommendations for
changes to our final policies.
Response: We appreciate the commenters' suggestions. However, the
payment policies for the revised ASC payment system that are addressed
by the commenters were finalized in the August 2, 2007 revised ASC
payment system final rule after we received and addressed public
comments. Therefore, we are not addressing these comments in this final
rule with comment period. Only the comments we received during the
comment period related to the proposed annual update of the revised ASC
payment system that were included in the August 2, 2007 OPPS/ASC
proposed rule are addressed in this final rule with comment period. Any
additional changes to the payment policies in that final rule would
need to be subjected to the notice and comment rulemaking procedures
through issuance of a proposed rule before any such changes could be
finalized.
Comment: Several commenters recommended that CMS establish an
advisory group of clinically-trained ASC experts to work with CMS staff
prior to release of the annual proposed rule to review and provide
clinical safety and procedure-specific data on procedures that CMS may
initially deem a safety risk.
Response: We appreciate the commenters' suggestion. However, we
believe that the current process for identifying procedures for
exclusion from the list of covered procedures is sufficient. The
process we have established allows for clinical review by our medical
staff and expert advisors, as well as comments from the public on an
annual basis prior to making final decisions regarding surgical
procedures for exclusion from the list of ASC covered surgical
procedures. Further, in contrast to the biennial process to update the
ASC list under the existing ASC payment system in effect through CY
2007, the process for updating the list annually under the revised
payment system increases opportunities for the public to comment on our
proposed changes to the list and other aspects of the payment system
that may be included in the proposed rule.
Comment: One commenter suggested CMS should develop and implement
modifiers for hospitals and ASCs to use to monitor beneficiaries who,
after undergoing procedures in ASCs, are discharged to hospitals. The
commenter stated that, with the greatly expanded list of covered
surgical procedures in place, ASCs will be prone to provide services
that are beyond their capabilities. The commenter believed that ASCs
may underestimate the severity of certain types of patients or cases,
or both, and that as a result, beneficiaries requiring continued care
will be transferred to the hospital. The commenter argued that this
would result in increased health care costs. The commenter believed
that, in this way, the revised ASC payment system may introduce payment
inequities whereby hospitals lose money by caring for patients
transferred from ASCs, many times for hospital outpatient services that
would not be paid by Medicare under existing OPPS payment policy.
Further, the commenter was concerned that transferred beneficiaries
also may be exposed to increased financial liability for hospital
services not covered by Medicare under the OPPS and that the quality of
care would
[[Page 66831]]
suffer due to the transfer, which would require the involvement of
multiple providers. For those reasons, the commenter suggested that CMS
develop and implement a method to monitor ASC-to-hospital transfer
activity.
Response: We do not anticipate a significant influx of transfers
from ASCs to hospitals to accompany implementation of the revised
payment system. As discussed above, we have an established review
policy to identify and exclude from ASC payment those procedures that
could pose a significant safety risk to beneficiaries when performed in
the ASC setting or that are expected to require an overnight stay. We
have expanded the ASC list of covered surgical procedures in order to
increase physicians' choices when selecting the most appropriate place
of care for beneficiaries. To this end, the implementation of the
revised ratesetting methodology removes site-of-service payment
differentials that may have affected physicians' decisions in the past.
We believe that, under the revised payment system, physicians will
choose the setting for a procedure that best suits the needs of the
individual beneficiary, and that beneficiaries will benefit from
expanded access to surgical services in the most efficient and
appropriate setting available.
Thus, although we are sensitive to the commenter's concerns, we see
no reason to implement modifiers as suggested by the commenter at this
time. We will continue to analyze claims and other available data
during our annual rulemaking cycle to assess the effectiveness of our
policies and to make our annual updates.
2. Covered Ancillary Services Under the Revised ASC Payment System
a. General Policies
As described in Sec. 416.163, payment is made under the revised
ASC payment system for ASC services furnished in connection with
covered surgical procedures. As set forth in Sec. 416.2, ASC services
include both facility services, which are defined as services that are
furnished in connection with a covered surgical procedure performed in
an ASC and for which payment is packaged into the ASC payment for the
covered surgical procedure, and covered ancillary services, which are
defined as those items and services that are integral to a covered
surgical procedure performed in an ASC, for which separate payment is
made under the revised ASC payment system.
``Covered ancillary services'' include the following, as specified
in Sec. 416.164(b): brachytherapy sources; certain implantable items
that have pass-through status under the OPPS; certain items and
services that we designate as contractor-priced (payment rate is
determined by the Medicare contractor) including, but not limited to,
the procurement of corneal tissue; certain drugs and biologicals for
which separate payment is allowed under the OPPS; and certain radiology
services for which separate payment is allowed under the OPPS.
Under the revised ASC payment system, we designate specific
services that are separately payable under the OPPS as ``covered
ancillary services'' and make separate payment to ASCs when any of the
services so designated are provided on the same day as integral to a
covered surgical procedure provided in the ASC (72 FR 42477). Payment
for ancillary services that are packaged under the OPPS also is
packaged under the revised ASC payment system (and those services are
not considered to be ASC covered ancillary services). Furthermore, only
the ASC can receive payment for the facility resources required to
provide the covered ancillary radiology or other covered ancillary
services, and ASCs are no longer able to bill as independent diagnostic
testing facility (IDTF) suppliers to receive payment for ancillary
radiology services that are integral to the performance of a covered
surgical procedure for which the ASC is billing Medicare.
We continue to consider to be outside the scope of ASC services, as
set forth in Sec. 416.164(c), the following items and services,
including, but not limited to: physicians' services (including surgical
procedures and all preoperative and postoperative services that are
performed by a physician); anesthetists' services; radiology services
(other than those integral to performance of a covered surgical
procedure); diagnostic procedures (other than those directly related to
performance of a covered surgical procedure); ambulance services; leg
arm, back, and neck braces other than those that serve the function of
a cast or splint; artificial limbs; and nonimplantable prosthetic
devices and DME.
We received one public comment specific to our general final
payment policy for separate payment of covered ancillary services in
ASCs under the revised ASC payment system. A summary of the public
comment and our response follow.
Comment: MedPAC expressed concern regarding our final payment
policy under the revised ASC payment system for covered ancillary
services. The revised ASC payment system pays separately for covered
ancillary services in order to align the ASC payment bundles with the
OPPS. However, MedPAC was concerned that separate payment for these
services for which payment is currently packaged under the existing ASC
payment system may lead to growth of the covered ancillary services in
ASCs. MedPAC recommended that CMS pursue broader packaging policies for
both ASCs and the OPPS to promote efficient resource use in both
settings.
Response: We appreciate this comment from MedPAC, and as evidenced
by the packaging approach that we are finalizing for the CY 2008 OPPS,
as described in section II.A.4.c. of this final rule with comment
period, we are expanding the packaging of ancillary services to
increase the size of the payment bundles in both the OPPS and ASC
settings. In particular, there are a number of radiology services,
including guidance procedures, that are newly packaged under the OPPS,
but which otherwise would have been paid separately in the ASC setting
as covered ancillary services. We do not expect significant growth of
separately payable covered ancillary services in ASCs as a direct
result of providing separate payment for these services beginning in CY
2008 because, to be paid, these services must always be provided
integral to covered surgical procedures in ASCs.
As discussed above, we have revised the ASC payment system to more
appropriately pay for surgical procedures that are covered in that
setting; that is, those procedures we have determined do not pose a
significant risk to beneficiary safety and would not be expected to
require an overnight stay. Because we are paying for these surgical
procedures using the OPPS APCs as the grouper, we believe it is most
appropriate to align the payment bundles under the OPPS and the revised
ASC payment system. Increased packaging under the OPPS that alters the
OPPS payment bundles will also occur under the revised ASC payment
system. We believe that the changes to the ASC payment system will
allow beneficiaries to receive the care they require in the most
appropriate setting and ASCs to be appropriately paid for that care. We
have no reason to believe that increased service growth for covered
ancillary services provided in ASCs will be more likely than growth for
those services provided in other settings.
[[Page 66832]]
b. Payment Policies for Specific Items and Services
(1) Radiology Services
Under the revised ASC payment system, we designate as ``covered
ancillary services'' those ancillary radiology services that are
separately payable under the OPPS. Thus, ASCs receive a separate
payment for a covered ancillary radiology service which, by definition,
is provided in the ASC integral to the performance of a covered
surgical procedure. ASC payment for those covered ancillary services is
at the lower of the rate developed according to the standard
methodology of the revised ASC payment system or the MPFS nonfacility
PE RVU amount (specifically for the technical component (TC) if the
service is assigned a TC under the MPFS). No separate payment is made
for ancillary services that are designated as packaged under the OPPS.
We specify that a covered ancillary radiology service is integral to
the performance of a covered surgical procedure if it is required for
the successful performance of the surgery and is performed in the ASC
immediately preceding, during, or immediately following the covered
surgical procedure. Payment under the revised ASC payment system for
covered ancillary radiology services is subject to geographic
adjustment, like payment for ASC surgical procedures. Only the ASC can
receive payment for the facility resources required to provide the
covered ancillary radiology services, and ASCs are no longer able to
bill as independent diagnostic testing facility (IDTF) suppliers to
receive payment for any ancillary radiology services that are integral
to the performance of a covered surgical procedure for which the ASC is
billing Medicare. Because the packaging status of radiology services
under the revised ASC payment system parallels the OPPS, any changes to
the packaging of radiology services under the OPPS will also occur
under the revised ASC payment system.
Ancillary radiology services include all Category I CPT codes in
the radiology range established by CPT, from 70000 to 79999, and
Category III CPT codes and Level II HCPCS codes that describe radiology
services that crosswalk or are clinically similar to procedures in the
radiology range established by CPT. This revised ASC payment system
policy for each calendar year applies to all radiology services that
are separately payable under the OPPS in that same calendar year. A
list that includes all covered ancillary radiology services may be
found in Addendum BB to this final rule with comment period. Covered
ancillary radiology services are assigned payment indicator ``Z2''
(Radiology service paid separately when provided integral to a surgical
procedure on ASC list; payment based on OPPS relative payment weight)
or ``Z3'' (Radiology service paid separately when provided integral to
a surgical procedure on ASC list; payment based on MPFS nonfacility PE
RVUs). Payment for ancillary radiology services that are packaged under
the OPPS is packaged under the revised ASC payment system, and those
services are identified in Addendum BB to this final rule with comment
period with payment indicator ``N1'' (Packaged service/item; no
separate payment made). ASC payment for covered ancillary radiology
services is not subject to the 4-year transition.
(2) Brachytherapy Sources
Under the revised ASC payment system, we designate as ``covered
ancillary services'' those brachytherapy sources that are separately
payable under the OPPS. Thus, ASCs receive separate payment for those
covered ancillary brachytherapy sources that are implanted in
conjunction with covered surgical procedures billed by ASCs. The
application of the brachytherapy sources is integrally related to the
covered surgical procedures for insertion of brachytherapy needles and
catheters. There is a statutory requirement that the OPPS establish
separate payment groups for brachytherapy sources related to their
number, radioisotope, and radioactive intensity, as well as for
stranded and non-stranded sources as of July 1, 2007. OPPS procedure
payments specifically do not include payment for brachytherapy sources.
The ASC brachytherapy source payment rate for a given calendar year is
the same as the OPPS payment rate for that year, without application of
the ASC budget neutrality adjustment or, if specific OPPS prospective
payment rates are unavailable, ASC payments for brachytherapy sources
are contractor-priced. In addition, consistent with the payment of
brachytherapy sources under the OPPS, the ASC payment rates for
brachytherapy sources are not adjusted for geographic wage differences.
The Level II HCPCS codes for brachytherapy sources and their payment
rates under the CY 2008 revised ASC payment system, the same as those
finalized for the CY 2008 OPPS, are included in Addendum BB to this
final rule with comment period. Brachytherapy sources are assigned
payment indicator ``H2'' (Brachytherapy source paid separately when
provided integral to a surgical procedure on ASC list; payment based on
OPPS rate). We note that we are finalizing our proposal to change the
brachytherapy source payment indicator from ``H4,'' defined as
``Brachytherapy source paid separately when provided integral to a
surgical procedure on ASC list; payment contractor-priced'' to ``H2,''
in order to be consistent with the final CY 2008 OPPS policy for
payment of brachytherapy sources, as described in section VII. of this
final rule with comment period. For CY 2008, we are paying under the
OPPS at prospective rates calculated from historical claims data and,
therefore, the ASC payment for brachytherapy sources will be at those
same rates. The HCPCS codes for all brachytherapy sources and their ASC
payment amounts and ASC payment indicators are listed in Table 47
below.
Table 47.--CY 2008 Payments for Brachytherapy Sources Implanted in ASCs
------------------------------------------------------------------------
ASC payment CY 2008 ASC
HCPCS code Short descriptor indicator payment rate
------------------------------------------------------------------------
A9527............. Iodine I-125 H2............... $27.55
sodium iodide.
C1716............. Brachytx, non- H2............... 33.30
str, Gold-198.
C1717............. Brachytx, non- H2............... 175.19
str, HDR Ir-192.
C1719............. Brachytx, NS, Non- H2............... 65.13
HDRIr-192.
C2616............. Brachytx, non- H2............... 11,764.95
str,Yttrium-90.
C2634............. Brachytx, non- H2............... 30.94
str, HA, I-125.
C2635............. Brachytx, non- H2............... 46.92
str, HA, P-103.
C2636............. Brachy linear, H2............... 42.04
non-str, P-103.
C2638............. Brachytx, H2............... 45.31
stranded, I-125.
[[Page 66833]]
C2639............. Brachytx, non- H2............... 32.10
stranded, I-125.
C2640............. Brachytx, H2............... 65.66
stranded, P-103.
C2641............. Brachytx, non- H2............... 51.45
stranded, P-103.
C2642............. Brachytx, H2............... 97.72
stranded, C-131.
C2643............. Brachytx, non- H2............... 64.08
stranded, C-131.
C2698............. Brachytx, H2............... 45.31
stranded, NOS.
C2699............. Brachytx, non- H2............... 30.94
stranded, NOS.
------------------------------------------------------------------------
(3) Drugs and Biologicals
Under the revised ASC payment system, we designate as ``covered
ancillary services'' all drugs and biologicals that are separately paid
under the OPPS. Thus, ASCs receive separate payment for those covered
ancillary drugs and biologicals which, by definition, are provided
integral to a covered surgical procedure performed in an ASC. We
specify that a drug or biological is integral to a covered surgical
procedure if it is required for the successful performance of the
surgery and is provided to the beneficiary in the ASC immediately
preceding, during, or immediately following the covered surgical
procedure. Payments for covered ancillary drugs and biologicals under
the revised ASC payment system for a calendar year are equal to the
OPPS payment rates for those drugs and biologicals that same year,
without application of the ASC budget neutrality adjustment. In
addition, consistent with the payment of drugs and biologicals under
the OPPS, the ASC payment rates for these items are not adjusted for
geographic wage differences.
A list of the covered ancillary drugs and biologicals under the CY
2008 revised ASC payment system and their payment rates are included in
Addendum BB to this final rule with comment period. Covered ancillary
drugs and biologicals are assigned payment indicator ``K2'' (Drugs and
biologicals paid separately when provided integral to a surgical
procedure on ASC list; payment based on OPPS rate). Ancillary drugs and
biologicals for which payment is packaged into the ASC payment for the
covered surgical procedure in CY 2008 are also listed in Addendum BB,
and are assigned payment indicator ``N1'' (Packaged service/item; no
separate payment made).
(4) Implantable Devices With Pass-Through Status Under the OPPS
Under the revised ASC payment system, we provide separate payment
at contractor-priced rates for devices that are included in device
categories with pass through status under the OPPS when the devices are
an integral part of a covered surgical procedure. As we have specified
for other services designated as covered ancillary services, a pass-
through device would be considered integral to the covered surgical
procedure when it is required for the successful performance of the
procedure; is provided in the ASC immediately before, during, or
immediately following the covered surgical procedure; and is billed by
the ASC on the same day as the covered surgical procedure.
In the future, new device categories may be established that will
have OPPS pass through status during all or a portion of any calendar
year. For CY 2008, there are two device categories with OPPS pass-
through status that are continuing in that status under the OPPS for CY
2008, specifically HCPCS code C1821 (Interspinous process distraction
device (implantable)) and HCPCS code L8690 (Auditory osseointegrated
device, includes all internal and external components). We note that
only the surgical procedures associated with the implantation of HCPCS
code L8690 are ASC covered surgical procedures for CY 2008. As under
the OPPS, ASC payment for covered ancillary services, including pass-
through devices, is not subject to the geographic wage adjustment.
The pass-through device category HCPCS codes are included in
Addendum BB to this final rule with comment period and are assigned
payment indicator ``J7'' (OPPS pass through device paid separately when
provided integral to a surgical procedure on ASC list; payment
contractor-priced). Implantable devices that receive packaged payment
because they do not have OPPS pass-through status are also listed in
Addendum BB to this final rule with comment period, where they are
assigned payment indicator ``N1'' (Packaged service/item; no separate
payment made).
The associated nondevice facility resources for the device
implantation procedures are paid through the ASC surgical procedure
service payment, based upon the payment weight for the nondevice
portion of the related OPPS APC payment weight.
(5) Corneal Tissue Acquisition
Under the revised ASC payment system, we pay separately for corneal
tissue procurement provided integral to the performance of an ASC
covered surgical procedure based on invoice costs. The HCPCS code for
corneal tissue acquisition, V2785 (Processing, preserving and
transporting corneal tissue), is listed in Addendum BB to this final
rule with comment period rule, and it is assigned payment indicator
``F4'' (Corneal tissue processing; paid at reasonable cost).
3. General Payment Policies
a. Adjustment for Geographic Wage Differences
Under the revised ASC payment system policy, we utilize 50 percent
as the labor related share to adjust national ASC payment rates for
geographic wage differences. Fifty percent is significantly higher than
the labor-related share used for the ASC payment system through CY 2007
(34.45 percent) but is also lower than the OPPS labor-related share of
60 percent, a differential we believe is appropriate given the broader
range of labor-intensive services provided in the HOPD setting.
We apply to ASC payments the IPPS pre-reclassification wage index
values associated with the June 2003 OMB geographic localities, as
recognized under the IPPS and OPPS, in order to adjust the labor-
related portion of the national ASC payment rates for geographic wage
differences. b. Beneficiary Coinsurance
Under the revised ASC payment system, beneficiary coinsurance
remains at 20 percent for ASC services, except for screening flexible
sigmoidoscopy and screening colonoscopy procedures. The coinsurance for
screening
[[Page 66834]]
colonoscopies and screening flexible sigmoidoscopies is 25 percent, as
required by section 1834(d) of the Act, with no deductible for those
services under the revised ASC payment system.
Comment: Several commenters suggested that CMS limit the
beneficiary coinsurance amount for ASC services to the Medicare Part A
hospital deductible, as occurs under the OPPS. The commenters stated
that the potential for higher coinsurance in the ASC setting could have
a negative financial impact on beneficiaries.
Response: Although this comment is outside of the scope for this
final rule with comment period, we are responding in order to provide
further clarification to interested stakeholders. The revised ASC
payment system results in many different payment rates effective
January 1, 2008, some lower than under the existing system and some
higher. The final beneficiary coinsurance policy may be found in the
August 2, 2007 revised ASC payment system final rule (72 FR 42519). For
the first year of the revised payment system in CY 2008, there are 171
procedures with payment rates higher than $1,339, the highest rate
under the existing ASC payment system. That means that beneficiary
liability for those procedures will be greater under the revised
payment system than under the existing ASC payment system. Of those
procedures, 27 will result in beneficiary liability that is greater
than the CY 2008 Medicare Part A hospital deductible amount of $1,024.
While we have statutory authority to limit beneficiary copayments
under the OPPS to no more than the Medicare Part A deductible for the
year, Medicare program payments to ASCs are required by section
1833(a)(1)(G) of the Act to be 80 percent of the lesser of the payment
amount or actual ASC charges, and beneficiaries are responsible for the
remaining 20 percent. We have no authority to revise those policies.
However, we point out that the coinsurance amounts under the revised
ASC payment system are limited to 20 percent of the payment rate and,
as such, other than for the 27 procedures noted above, are almost
without exception lower than the copayment amounts under the OPPS
because most of the ASC rates are lower than OPPS rates and because
beneficiary copayments vary from 20 to 40 percent under the OPPS. We
note that, just like under the OPPS, the ASC coinsurance amounts are
applied to each separate payment made for covered surgical procedures
and covered ancillary services.
D. Treatment of New HCPCS Codes
1. Treatment of New CY 2008 Category I and III CPT Codes and Level II
HCPCS Codes
We finalized a policy in the August 2, 2007 revised ASC payment
system final rule to evaluate each year all new HCPCS codes that
describe surgical procedures to make preliminary determinations in the
annual OPPS/ASC final rule with comment period regarding whether or not
they meet the criteria for payment in the ASC setting and, if so,
whether they are office-based procedures. These interim determinations
must be made in the OPPS/ASC final rule with comment period because the
new HCPCS codes and their descriptors for the upcoming calendar year
are not available at the time of development of the OPPS/ASC proposed
rule. In the absence of claims data that indicate where procedures
described by new codes are being performed and reflect the facility
resources required to perform them, we use other available information
to make interim decisions regarding assignment of payment indicators
for the new codes. The other sources available to us include our
clinical advisors' judgment, data regarding predecessor and related
HCPCS codes, information submitted by representatives of specialty
societies and professional associations, and information submitted by
commenters during the public comment period following publication of
the final rule with comment period in the Federal Register. Each year,
we will publish in the annual OPPS/ASC payment update final rule the
interim ASC determinations for the new codes to be effective January 1
of the update year. The interim payment indicators assigned to new
codes under the revised ASC payment system will be subject to comment
on that final rule. We will respond to those comments in the OPPS/ASC
update final rule for the following calendar year, just as we currently
respond to comments about APC and status indicator assignments for new
procedure codes in the OPPS update final rule for the year following
publication of the code's interim OPPS treatment.
After our review of public comments and in the absence of
physicians'' claims data, our determination that a new code is an
office based procedure and is, thereby, subject to the payment
limitation, will remain temporary and subject to review, until there
are adequate data available to assess the procedure's predominant sites
of service. Using those data, if we confirm our determination that the
new code is office-based after taking into account the volume and
utilization data for the procedure code and/or, if appropriate, the
clinical characteristics, utilization, and volume of related codes, the
code will be assigned permanently to the list of office-based
procedures subject to the ASC payment limitation, as discussed in
section XVI.C.1.c.(2) of this final rule with comment period.
New HCPCS codes for ASC implementation on January 1, 2008 are
designated in Addenda AA and BB to this OPPS/ASC final rule with
comment period with comment indicator ``NI.'' The ``NI'' comment
indicator is used to identify those HCPCS codes for which the assigned
ASC payment indicator is subject to public comment. (We refer readers
to section XVI.J. of this final rule with comment period for a
discussion of the ASC payment and comment indicators.)
2. Treatment of New Mid-Year Category III 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. The AMA established Category III CPT codes to allow
collection of data specific to the service described by the code which
otherwise only could 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.
CMS provides predictable quarterly updates for the OPPS throughout
each calendar year (January, April, July, and October), and the final
payment policies of the revised ASC payment system parallel, in many
cases, the OPPS treatment of HCPCS codes. As discussed in the August 2,
2007 revised ASC payment system final rule, we also provide quarterly
ASC updates for each calendar quarter to recognize newly created HCPCS
codes for ASC payment and to update the payment rates for separately
paid drugs and biologicals based on the most recently submitted ASP
data.
Under the OPPS and MPFS, CMS allows Category III CPT codes that are
released by the AMA in January to be effective beginning July of the
same calendar year in which they are issued, rather than deferring
implementation of those codes to the following calendar year update of
the payment systems, as is the case for the CPT Category I and Category
III codes that are released in July by the AMA for implementation in
January of the upcoming calendar year. Thus, new Category III CPT codes
are
[[Page 66835]]
made effective under the MPFS and OPPS biannually. In order to be
consistent in this regard across the three payment systems, in the CY
2008 OPPS/ASC proposed rule (72 FR 42783), we proposed to adopt that
same policy under the revised ASC payment system.
Some of the new Category III CPT codes may describe services that
our clinical advisors determine directly crosswalk or are clinically
similar to HCPCS codes that describe ASC covered surgical procedures.
In those instances, we may allow ASC payment for new Category III CPT
codes as covered surgical procedures. Similarly, a new code may
represent an ancillary service that directly crosswalks or is
clinically similar to an ancillary service for which separate ASC
payment is allowed when it is performed integral to an ASC covered
surgical procedure, and, as such, the new code also may be determined
to be eligible for ASC payment as a covered ancillary service.
We did not receive any public comments regarding our proposal to
recognize for ASC payment new CPT Category III codes, as appropriate,
in July of each year as we do under the OPPS and MPFS. Therefore,
beginning in CY 2008, we are including in the July quarterly update to
the ASC payment system, the ASC payment indicators for new Category III
CPT codes that the AMA releases in January, and that we determine are
appropriate ASC covered surgical procedures or covered ancillary
services for implementation, as payable in ASCs beginning in July of
the same year. Likewise, as described above, we will implement annually
for payment in the January update of the ASC payment system any of the
Category III CPT codes that the AMA released the previous July, along
with new Category I CPT codes that are determined to be appropriate for
ASC payment. Interim ASC payment indicators will be assigned to those
new mid-year Category III CPT codes that are released in January for
implementation in July of a given calendar year, and the interim ASC
indicators will be open to comment in the OPPS/ASC proposed rule for
the following calendar year and their status will be made final in the
update year's final rule.
Of the Category III CPT codes the AMA released January 1, 2007, we
have determined that only one is appropriate for payment in ASCs as a
covered ancillary radiology service. The new CPT code is 0182T (High
dose rate electronic brachytherapy, per fraction), and we proposed to
assign it to the list of covered ancillary services with payment
indicator ``Z2'' for payment in ASCs beginning January 1, 2008. This
service has no MPFS nonfacility PE RVUs assigned to it. Therefore, we
proposed that its CY 2008 ASC payment be calculated according to the
standard ASC payment system methodology, based on the code's OPPS
relative payment weight.
We do not believe that any of the other Category III CPT codes
released in January 2007 for implementation in July 2007 meet the
criteria for inclusion on the ASC list of covered surgical procedures
or covered ancillary services because they do not directly crosswalk
and are not clinically similar to established covered ASC services.
We did not receive any public comments about our proposed
assignment of ASC payment indicator ``Z2'' to CPT code 0182T.
Therefore, we are finalizing our assignment of ASC payment indicator
``Z2'' to CPT code 0182T for CY 2008.
3. Treatment of Level II HCPCS Codes Released on a Quarterly Basis
In addition to the Category III CPT codes that are released twice
each year, new Level II HCPCS codes may be created more frequently and
are implemented for the MPFS and OPPS on a quarterly basis. Level II
HCPCS codes are most commonly created for the purpose of reporting new
drugs and biologicals but also are created for reporting some surgical
procedures and other services for which payment may be made under the
revised ASC payment system, as it is under the OPPS.
We base the ASC payment policies for covered surgical procedures,
drugs, biologicals, and certain other covered ancillary services
integral to ASC covered surgical procedures on the OPPS. Therefore, we
proposed to update the coding and payment for the services in ASCs at
the same time that the OPPS is updated. We proposed to recognize newly
created Level II HCPCS codes under the revised ASC payment system for
payment on a quarterly basis, consistent with the quarterly updates to
the OPPS. Just as we provide a predictable quarterly update for the
OPPS occurring throughout each calendar year (January, April, July, and
October), we also would provide predictable quarterly updates for ASCs
to recognize newly created Level II HCPCS codes for ASC payment and to
update the payment rates for separately paid drugs and biologicals
based on the most recently submitted ASP data.
In the CY 2008 OPPS/ASC proposed rule, we also proposed to update
the lists of covered surgical procedures and ancillary services that
qualify for separate payment in ASCs in CY 2008 by adding eight new CY
2007 Level II HCPCS codes that were implemented in the OPPS in July
2007. Because of the timing of the proposed rule, the new Level II
HCPCS codes implemented through the July 2007 OPPS update were not
included in Addendum BB to the proposed rule.
We did not receive any comments regarding the proposed payment
indicators for the eight new CY 2007 Level II HCPCS codes that were
implemented in the OPPS in July 2007. Therefore, we are finalizing our
payment for them in the ASC setting, as proposed. The eight codes are
listed in Table 48 below, as well as in Addendum BB to this final rule
with comment. Beginning in CY 2008, with implementation of the revised
ASC payment system, the Level II HCPCS codes describing new procedures,
drugs, and biologicals will be payable in ASCs in the same calendar
quarter as they are initially paid under the OPPS.
We assigned payment indicator ``K2'' to seven of the eight new
codes for drugs to indicate that separate payment will be made for
those drugs when they are provided to beneficiaries in ASCs integral to
covered surgical procedures. Level II HCPCS code C9728 (Placement of
interstitial device(s) for radiation/surgery guidance (e.g., fiducial
markers, dosimeter), other than prostate (any approach), single or
multiple) is a covered surgical procedure with payment indicator ``R2''
because it is clinically similar to CPT code 55876 (Placement of
interstitial device(s) for radiation therapy guidance (e.g., fiducial
markers, dosimeter), prostate (via needle, any approach), single or
multiple) that we have included on the list of covered surgical
procedures with a payment indicator of ``P3.'' While we believe both
procedures are office-based, there are currently no MPFS nonfacility PE
RVUs available for the Level II HCPCS code C9728, which was initially
established in response to a New Technology APC application under the
OPPS, and, therefore, its payment indicator is ``R2.''
[[Page 66836]]
Table 48.--Level II HCPCS Codes Implemented Under the OPPS in July 2007
That Will Be Paid in CY 2008 in ASCS
------------------------------------------------------------------------
CY 2008 ASC
CY 2007 HCPCS CY 2008 HCPCS Descriptor payment
code code indicator
------------------------------------------------------------------------
C9728............ C9728............ Placement of R2
interstitial
device(s) for
radiation
therapy/surgery
guidance (e.g.,
fiducial
markers,
dosimeter),
other than
prostate (any
approach),
single or
multiple.
Q4087............ J1568............ Injection, K2
immune
globulin,
(Octagam),
intravenous,
non-
lyophilized,
(e.g. liquid),
500 mg.
Q4088............ J1569............ Injection, K2
immune
globulin,
(Gammagard
Liquid),
intravenous,
non-
lyophilized,
(e.g. liquid),
500 mg.
Q4089............ J2791............ Injection, K2
rho(d) immune
globulin
(human),
(Rhophylac),
intravenous,
100 iu.
Q4090............ J1571............ Injection, K2
hepatitis b
immune globulin
(Hepagam B),
intramuscular,
0.5 ml.
Q4091............ J1572............ Injection, K2
immune
globulin,
(Flebogamma),
intravenous,
non-lyophilized
(e.g. liquid),
500 mg.
Q4092............ J1561............ Injection, K2
immune
globulin,
(Gamunex),
intravenous,
non-lyophilized
(e.g. liquid),
500 mg.
Q4095............ J3488............ Injection, K2
zoledronic acid
(Reclast), 1 mg.
------------------------------------------------------------------------
We did not receive any public comments regarding our proposal to
implement new Level II HCPCS codes for ASC payment on a quarterly basis
each year and new Category III CPT codes on a semiannual basis, to
parallel the policies under the MPFS and OPPS for the recognition of
those codes. Therefore, beginning in CY 2008 with implementation of the
revised ASC payment system, we are implementing new Level II HCPCS
codes for ASC payment on a quarterly basis each year and new Category
III CPT codes on a semiannual basis, to parallel the policies under the
MPFS and OPPS for the recognition of those codes. Also, consistent with
the MPFS and OPPS policies, our final policy with regard to HCPCS codes
implemented on January 1 of a calendar year is to publish the new codes
and interim payment indicators annually in the OPPS/ASC final rule with
comment period.
E. Updates to Covered Surgical Procedures and Covered Ancillary
Services
1. Identification of Covered Surgical Procedures
a. General Policies
We published Addendum AA to the August 2, 2007 revised ASC payment
system final rule as an illustrative list of covered surgical
procedures and payment rates for the revised ASC payment system to be
implemented January 1, 2008. The final rule established our policies
for determining which procedures are eligible to be considered ASC
covered surgical procedures and, of those, which are excluded from ASC
payment because they pose a significant risk to beneficiary safety or
would be expected to require an overnight stay. We adopted a definition
of surgical procedure for the revised ASC payment system as those
procedures described by all Category I CPT codes in the surgical range
from 10000 through 69999 except unlisted procedure codes, as well as
those Category III CPT codes and Level II HCPCS codes that crosswalk or
are clinically similar to ASC covered surgical procedures.
Section 1833(i)(1) of the Act requires us to review and update the
list of ASC procedures at least every 2 years. We finalized our policy
to update the ASC list of covered surgical procedures annually, in
conjunction with annual proposed and final rulemaking to update the
OPPS and ASC payment systems. Each year we undertake a review of
excluded procedures, new procedures, and procedures for which there is
revised coding to identify any that we believe are appropriate for
coverage in ASCs because they do not pose significant risks to
beneficiary safety and would not be expected to require overnight
stays.
In the August 2, 2007 revised ASC payment system final rule, we
finalized the addition of approximately 790 new covered surgical
procedures for payment under the revised ASC payment system beginning
in CY 2008. In the CY 2008 OPPS/ASC proposed rule, we proposed to
remove 13 procedures from the OPPS inpatient list and, of those 13, we
believe that 3 are safe for performance in ASCs. Therefore, we proposed
to add the following three additional surgical procedures to the ASC
list of covered surgical procedures eligible for Medicare ASC payment
in CY 2008: CPT codes 25931 (Amputation, forearm, through radius and
ulna; re-amputation); 50580 (Renal endoscopy through nephrotomy or
pyelotomy, with or without irrigation, instillation, or
uteropyelography, exclusive of radiologic service; with removal of
foreign body or calculus); and 58805 (Drainage of ovarian cyst(s),
unilateral or bilateral, (separate procedure); abdominal approach).
We did not receive any public comments about our proposal to
designate CPT codes 25931, 50580, and 58805 as payable in ASCs as
covered surgical procedures beginning CY 2008. Therefore, we are
finalizing our proposal to designate the three procedures as payable in
ASCs as covered surgical procedures, assigning them payment indicator
``G2,'' beginning in CY 2008.
In the CY 2008 OPPS/ASC proposed rule, we also solicited comments
and recommendations regarding additional surgical procedures that
commenters believe should not be excluded from ASC payment beginning in
CY 2008. We specifically encouraged commenters to provide evidence, to
the extent possible, to support their recommendations regarding
procedures and services they believe should not be excluded from ASC
payment.
We received many public comments from individuals and organizations
requesting that specific procedures be added or removed from the CY
2008 proposed list of ASC covered surgical procedures. A summary of the
public comments and our responses follow.
Comment: Some commenters stated that certain procedures CMS had
proposed to exclude from coverage as payable in ASCs do not pose a risk
to beneficiary safety and are not expected to require an overnight
stay, and as such, should not be excluded from the ASC list. Table 49
below includes a list of all procedures for which the commenters
requested designation as covered surgical procedures in ASCs.
[[Page 66837]]
Table 49.--Specific Procedures That Commenters Requested Not Be Excluded
From ASC Payment in CY 2008
------------------------------------------------------------------------
HCPCS code Short descriptor
------------------------------------------------------------------------
0088T............................ Rf tongue base vol reduxn
0135T............................ Perq cryoablate renal tumor.
0137T............................ Prostate saturation sampling.
0170T............................ Anorectal fistula plug rpr.
0184T............................ Transanal resect rectal tumor.
0186T............................ Suprachoroidal drug delivery.
15170............................ Acell graft trunk/arms/legs.
15171............................ Acell graft t/arm/leg add-on.
15175............................ Acellular graft, f/n/hf/g.
15176............................ Acell graft, f/n/hf/g add-on.
21360............................ Treat cheek bone fracture.
21365............................ Treat cheek bone fracture.
21385............................ Treat eye socket fracture.
21386............................ Treat eye socket fracture.
21387............................ Treat eye socket fracture.
22526............................ Idet, single level.
22527............................ Idet, 1 or more levels.
27093............................ Injection for hip x-ray.
27096............................ Inject sacroiliac joint.
29866............................ Autgrft implnt, knee w/scope.
29867............................ Allgrft implnt, knee w/scope.
29868............................ Meniscal trnspl, knee w/scpe.
32998............................ Perq rf ablate tx, pul tumor.
35470............................ Repair arterial blockage.
35471............................ Repair arterial blockage.
35472............................ Repair arterial blockage.
35490............................ Atherectomy, percutaneous.
35491............................ Atherectomy, percutaneous.
35493............................ Atherectomy, percutaneous.
35494............................ Atherectomy, percutaneous.
35495............................ Atherectomy, percutaneous.
37182............................ Insert hepatic shunt (tips).
37182............................ Remove hepatic shunt (tips).
37201............................ Transcatheter therapy infuse.
37202............................ Transcatheter therapy infuse.
37204............................ Transcatheter occlusion.
37205............................ Transcath iv stent, precut.
37206............................ Transcath iv stent/perc addl.
37209............................ Change iv cath at thromb tx.
37210............................ Embolization uterine fibroid.
37620............................ Revision of major vein.
44300............................ Open bowel to skin.
44500............................ Intro, gastrointestinal tube.
44901............................ Drain app abscess, precut.
47011............................ Percut drain, liver lesion.
47490............................ Incision of gallbladder.
48511............................ Drain pancreatic pseudocyst.
49021............................ Drain abdominal abscess.
49041............................ Drain, percut, abdom abscess.
49061............................ Drain, percut, retroper absc.
50021............................ Renal abscess, percut drain.
50080............................ Removal of kidney stone.
50081............................ Removal of kidney stone.
58823............................ Drain pelvic abscess, precut.
62290............................ Inject for spine disk x-ray.
62291............................ Inject for spine disk x-ray.
63020............................ Neck spine disk surgery.
63030............................ Low back disk surgery.
63035............................ Spinal disk surgery add-on.
63040............................ Laminotomy, single cervical.
63042............................ Laminotomy, single lumbar.
63044............................ Laminotomy, add'l lumbar.
63047............................ Removal of spinal lamina.
63056............................ Decompress spinal cord.
64448............................ N block inj fem, cont inf.
64449............................ N block inj, lumbar plexus.
64910............................ Nerve repair w/allograft.
G0289............................ Arthro, loose body + chondro.
0171T............................ Lumbar spine process distract.
0172T............................ Lumbar spine process addl.
------------------------------------------------------------------------
Response: In response to the public comments received, our clinical
advisors evaluated each of the procedures listed in Table 49 to
determine whether it poses a significant safety risk to beneficiaries
or would be expected to require an overnight stay. Several of those
procedures, specifically CPT codes 27093 (Injection procedure for hip
arthrography); 62290 (Injection procedure for discography, each level;
lumbar) 62291 (Injection procedure for discography, each level;
cervical or thoracic); and G0289 (Arthroscopy, knee, surgical, for
removal of loose body, foreign body, debridement/shaving of articular
cartilage (chondroplasty) at the time of other surgical knee
arthroscopy in a different compartment of the same knee), are packaged
procedures under the OPPS and, therefore, are not eligible for
designation as separately payable procedures under the revised ASC
payment system. However, we note that these packaged procedures are
also not excluded from Medicare payment when performed in the ASC
setting. Their payment will be packaged into payment for the ASC
covered surgical procedure performed in the ASC.
As a result of our review of the other procedures listed in Table
49 that would be candidates for separate ASC payment according to their
OPPS payment policies, we are not excluding 11 additional procedures
from Medicare payment when performed in the ASC setting in CY 2008. In
making our determinations, even where procedures had high inpatient
utilization due to their frequent performance on hospital inpatients,
we considered the clinical characteristics of the surgical procedure
itself. As we stated in the August 2, 2007 revised ASC payment system
final rule, we examine all the clinical information regarding the
surgical procedure, including its inpatient utilization, to determine
whether or not a procedure would pose a significant risk to beneficiary
safety or would be expected to require an overnight stay if performed
in an ASC (72 FR 42482). Of the procedures that commenters requested
not be excluded from the list of covered surgical procedures, those
that we determined are appropriate for payment in an ASC and their
final CY 2008 payment indicators are displayed in Table 50.
Table 50.--Specific Procedures Newly Designated as Covered ASC Surgical
Procedures for CY 2008
------------------------------------------------------------------------
CY 2008 payment
HCPCS code Short descriptor indicator
------------------------------------------------------------------------
0088T................ Rf tongue vol reduxn..... G2
0137T................ Prostate saturation G2
sampling.
0170T................ Anorectal fistula plug G2
rpr.
0186T................ Suprachoroidal drug G2
delivery.
21360................ Treat cheek bone fracture G2
22526................ Idet, single level....... G2
22527................ Idet, 1 or more levels... G2
29866................ Autgrt implnt, knee w/ G2
scope.
32998................ Perq rf ablate tx, pul G2
tumor.
44500................ Intro, gastrointestinal G2
tube.
64910................ Nerve repair w/allograft. G2
------------------------------------------------------------------------
We determined that each of the remaining 57 procedures (those not
packaged or listed in Table 50) requested by the commenters and listed
in Table 49 would pose a significant risk to beneficiary safety or be
expected to require an overnight stay, so they will continue to be
excluded from the list of ASC covered surgical procedures for CY 2008.
A complete list of surgical procedures that are excluded from Medicare
payment when provided in ASCs may be found in Addendum EE posted on the
CMS Web site at: http://www.cms.hhs.gov/ASCPayment.
Comment: Several commenters requested that specific procedures be
removed from the ASC list of covered procedures in order to enhance the
safety and quality of care that is delivered by ASCs. The commenters
stated that CMS should exercise caution in granting patients and
physicians the flexibility to determine appropriate sites of care,
particularly for procedures that could have catastrophic outcomes if
the appropriate emergent care equipment and training are not available
in the site where care is delivered. Specifically, the commenters
requested removal of percutaneous transluminal angioplasty procedures,
transvenous electrode procedures, and certain cardiac electrophysiology
procedures, as well as palatal surgical procedures. Table 51 below
lists the procedures for which the
[[Page 66838]]
commenters requested removal from the ASC list of covered surgical
procedures.
Table 51.--Procedures Recommended by Commenters for Removal From the ASC
List of Covered Surgical Procedures
------------------------------------------------------------------------
HCPCS code Short descriptor
------------------------------------------------------------------------
33206............................ Insertion of heart pacemaker.
33207............................ Insertion of heart pacemaker.
33208............................ Insertion of heart pacemaker.
33214............................ Upgrade of pacemaker system.
33215............................ Reposition pacing-defib lead.
33216............................ Insert lead pace-defib, one.
33217............................ Insert lead pace-defib, dual.
33218............................ Repair lead pace-defib, one.
33220............................ Repair lead pace-defib, dual.
33224............................ Insert pacing lead & connect.
33225............................ L ventric pacing lead add-on.
33226............................ Reposition l ventric lead.
33234............................ Removal of pacemaker system.
33235............................ Removal pacemaker electrode.
33249............................ Eltrd/insert pace-defib.
35473............................ Repair arterial blockage.
35474............................ Repair arterial blockage.
35476............................ Repair venous blockage.
35492............................ Atherectomy, percutaneous.
42200............................ Reconstruct cleft palate.
42205............................ Reconstruct cleft palate.
42210............................ Reconstruct cleft palate.
42215............................ Reconstruct cleft palate.
42220............................ Reconstruct cleft palate.
------------------------------------------------------------------------
Response: In response to the public comments received, our clinical
advisors reevaluated each of the procedures listed in Table 51 to
determine whether it poses a significant safety risk to beneficiaries
or would be expected to require an overnight stay. We note that while
CPT codes 42200 (Palatoplasty for left palate, soft and/or hard palate
only); 42205 (Palatoplasty for cleft palate, with closure of alveolar
ridge; soft tissue only); 42210 (Palatoplasty for cleft palate; with
closure of alveolar ridge; with bone graft to alveolar ridge (includes
obtaining graft)); 42215 (Palatoplasty for cleft palate; major
revision); and 42220 (Palatoplasty for cleft palate; attachment
pharyngeal flap) were eligible for payment when performed in the ASC in
CY 2007, the remainder of the codes listed in Table 51 were added to
the ASC list of covered surgical procedures in the August 2, 2007
revised ASC payment system final rule for CY 2008.
We continue to believe that these palatoplasty procedures that have
been on the ASC list of covered surgical procedures for more than 5
years do not pose a significant risk to beneficiary safety in the ASC
setting, nor would they be expected to require an overnight stay. We
are not aware of any safety problems regarding the performance of these
procedures in ASCs over the years Medicare has included them on the
list of ASC covered surgical procedures.
With respect to the pacemaker and ICD lead placement,
repositioning, and removal procedures, we proposed a number of these
procedures for addition to the ASC list for CY 2008 in the August 23,
2006 proposed rule for the revised ASC payment system. We received a
number of comments on the proposed rule regarding these procedures, as
well as related surgical procedures, which we carefully reviewed prior
to placing them on the ASC list of covered surgical procedures in the
August 2, 2007 revised ASC payment system final rule. We have once
again examined these procedures in light of comments received on the CY
2008 OPPS/ASC proposed rule and, we believe, under the safety and
overnight stay criteria that were adopted to exclude procedures from
ASC payment, all of these procedures are appropriate for ASC
performance. In particular, we do not believe they pose a significant
safety risk, nor would be expected to require an overnight stay when
provided in ASCs.
We also closely reexamined the transluminal balloon angioplasty
services described by CPT codes 35473 (Transluminal balloon
angioplasty, percutaneous; iliac); 35474 (Transluminal balloon
angioplasty, percutaneous; femoral-popliteal); and 35476 (Transluminal
balloon angioplasty, percutaneous; venous). All three of these
procedures were proposed for addition to the ASC list for CY 2008 in
the August 23, 2006 OPPS/ASC proposed rule. We received requests to add
CPT code 36476 to the ASC list for CY 2007, but we did not add this
code at that point, based on the evaluation criteria for the existing
ASC payment system. We then added all three codes to the CY 2008 ASC
list in the August 2, 2007 revised ASC payment system final rule after
evaluating the public comments and concluding that the procedures
should not be excluded from ASC performance, consistent with the final
exclusion criteria for the revised system. In response to the comments
on the CY 2008 OPPS/ASC proposed rule that reflected the commenters'
ongoing concerns about the safety of these procedures in ASCs, our
clinical advisors engaged in a comprehensive assessment of their safety
based on current clinical practice patterns and the contemporary
medical literature. We have concluded that CPT codes 35473 and 35476 do
not pose a significant safety risk to beneficiaries nor would either
procedure be expected to require an overnight stay in ASCs. Therefore,
we are including CPT codes 35473 and 35476 on the CY 2008 ASC list of
covered surgical procedures. However, we have determined that CPT code
35474 would pose a significant safety risk to beneficiaries when
performed in an ASC. Therefore, we are excluding CPT code 35474 from
the CY 2008 ASC list of covered surgical procedures.
In summary, as a result of our review of the procedures the
commenters requested that we remove from the proposed CY 2008 ASC list
of covered surgical procedures, we are retaining all of the procedures
in Table 51 on the final CY 2008 list of ASC covered surgical
procedures except CPT code 35474. The full CY 2008 list of ASC covered
surgical procedures is included in Addendum AA to this final rule with
comment period.
b. Change in Designation of Covered Surgical Procedures as Office-Based
According to our final policy for the revised ASC payment system,
we designate as office-based procedures those that are added to the ASC
list of covered surgical procedures in CY 2008 or later years and that
we determine are predominantly performed in physicians' offices based
on consideration of the most recent available volume and utilization
data for each individual procedure code and/or, if appropriate, the
clinical characteristics, utilization, and volume of related codes.
The list of codes that we identified as office-based in the August
2, 2007 revised ASC payment system final rule took into account the
most recently available CY 2005 volume and utilization data for each
individual procedure code or related codes. In that rule, we finalized
our policy to apply the office-based designation only to procedures
that would no longer be excluded from ASC payment beginning in CY 2008
or later years and to exempt all procedures on the CY 2007 ASC list
from application of the office-based classification. We believe that
the resulting list accurately reflected Medicare practice patterns and
was clinically consistent. In Addendum AA to the August 2, 2007 revised
ASC payment system final rule, each of the office-based procedures was
identified by payment indicator ``P2,'' ``P3,'' or ``R2,'' depending on
whether we estimated it would be paid according to the standard ASC
payment methodology based on its OPPS relative payment weight or at the
MPFS nonfacility PE RVU amount.
Consistent with our final ASC policy to review and update annually
the surgical procedures for which ASC payment is made and to identify
new procedures that may be appropriate for
[[Page 66839]]
ASC payment, in developing the CY 2008 OPPS/ASC proposed rule, we
reviewed the CY 2006 utilization data for all those surgical procedures
newly added for ASC payment in CY 2008 that were assigned payment
indicator ``G2'' as nonoffice-based additions in the August 2, 2007
revised ASC payment system final rule. We based our evaluation of the
potential designation of a procedure as office-based on the most recent
available volume and utilization data for each individual procedure
code and/or, as appropriate, the clinical characteristics, utilization,
and volume of related codes. As a result of that review, we identified
19 procedures that were assigned payment indicator ``G2'' in the August
2, 2007 revised ASC payment system final rule that we proposed to
assign to the office-based procedure list, effective January 1, 2008,
with payment indicator ``P2,'' ``P3,'' or ``R2,'' as appropriate. We
refer readers to Addendum DD1 to this final rule with comment period
for the definitions of the ASC payment indicators.
In the CY 2008 OPPS/ASC proposed rule, we indicated that we would
consider comments submitted timely on the proposed designation of these
19 new procedures as office-based for CY 2008. For example, in the
August 2, 2007 revised ASC payment system final rule, payment indicator
``G2'' was assigned to CPT code 64650 (Chemodenervation of eccrine
glands; both axillae). After reviewing more recent CY 2006 data, we
discovered that the procedure is performed predominantly in physicians'
offices and we believed the procedure should be designated as an
office-based procedure. Therefore, we proposed to assign payment
indicator ``P3'' to CPT code 64650, effective for CY 2008. In the
proposed rule, we proposed to assign an office based payment indicator
for CPT code 64650 and 18 other procedures.
We also reviewed the five procedures that were assigned temporary
office-based payment indicators in the August 2, 2007 revised ASC
payment system final rule. Using CY 2006 data, we believed there were
adequate claims data for two of those procedures upon which to base
assignment of permanent payment indicators. Therefore, we proposed to
assign CPT code 36598 (Contrast injection(s) for radiologic evaluation
of existing central venous access device, including fluoroscopy, image
documentation and report) permanently to the office-based list, with
payment indicator ``P3'' for CY 2008. In the case of the second
procedure, CPT code 58110 (Endometrial sampling (biopsy) performed in
conjunction with colposcopy), in accordance with the CY 2008 OPPS
proposal to package its payment, we also proposed to package payment
for that procedure under the ASC payment system and assign it payment
indicator ``N1.''
We proposed to maintain the temporary office-based payment
indicator assignments for the other three procedures. We have only a
few claims for CPT code 0099T (Implantation of intrastromal corneal
ring segments) and no claims for CPT code 0124T (Conjunctival incision
with posterior juxtascleral placement of pharmacological agent (does
not include supply of medication)) or CPT code 55876 (Placement of
interstitial device(s) for radiation therapy guidance (e.g., fiduciary
markers, dosimeter), prostate (via needle, any approach), single or
multiple). We continue to believe these procedures are predominantly
office-based. Therefore, we proposed not to make any change to the
temporary office-based designation of these procedures at that time.
We received many public comments on our general payment policy for
office-based surgical procedures under the revised ASC payment system
and on our proposal to add 19 additional procedures to the office-based
list for CY 2008. A summary of the public comments and our responses
follow.
Comment: Many commenters opposed the policies related to the
designation of procedures as office-based and the subsequent payment
limitations for procedures that are so designated. Some commenters
recommended that, if CMS is going to maintain a list of office-based
procedures, it should restrict the criteria used to make office-based
determinations. They stated that designation of a procedure as office-
based should be made either based on utilization data for multiple
years or on the frequency of performance of the procedure in the HOPD
or ASC settings. The commenters stated that CMS's consideration of
clinical information and utilization data for related procedures is not
transparent, making it impossible for the public to assess whether its
determinations are rational and fair.
Several commenters specifically requested that one or more of the
19 additional procedures proposed for designation as office-based not
receive that designation. The commenters recommended that CMS not
finalize the proposal to designate 15 of the 19 procedures as office-
based because commenters believe they are not performed in physicians'
offices 50 percent or more of the time. Each of those codes the
commenters recommended not be designated as office-based is marked by a
plus (+) in Table 52 below.
Several commenters recommended that CMS not finalize the proposal
to designate CPT code 28890 (Extracorporeal shock wave, high energy,
performed by a physician, requiring anesthesia other than local,
including ultrasound guidance, involving the plantar fascia) as office-
based because they believe the CMS data that indicate the procedure's
performance in physicians' offices more than 50 percent of the time are
erroneous. The commenters stated that CMS assigned payment indicator
``G2'' to three high energy extracorporeal shock wave therapy (ESWT)
procedures, CPT codes 28890, 0101T (Extracorporeal shock wave involving
musculoskeletal system, not otherwise specified, high energy); and
0102T (Extracorporeal shock wave, high energy, performed by a
physician, requiring anesthesia other than local, involving lateral
humeral epicondyle) in the August 2, 2007 revised ASC payment system
final rule but then proposed to designate only CPT code 28890 as
office-based in the CY 2008 OPPS/ASC proposed rule. They stated that
CMS provided no explanation for the proposed change to the payment
indicator of CPT code 28890. Furthermore, the commenters argued that
the procedure is most appropriately provided in a facility setting and
that the proposed ASC payment for the procedure would be limited to the
MPFS nonfacility PE RVU amount, which is too low to cover the costs
associated with providing the procedure. The commenters recommended
that, because the CPT code was new for CY 2006, CMS should wait until
sufficient time has passed to collect and review adequate Medicare data
for its decision-making.
Another commenter requested that CMS not designate CPT codes 64650
(Chemodenervation of eccrine glands; both axillae) and 64653
(Chemodenervation of eccrine glands; other area(s) (e.g., scalp, face,
neck), per day) as office-based procedures because the codes were new
for CY 2006 and there are not yet adequate data on which to base that
determination.
Response: While we appreciate the concerns of commenters regarding
the limitation on payment for office-based procedures under the revised
ASC payment system, we note that we finalized that payment policy in
the August 2, 2007 revised ASC payment system final rule that set forth
the final policies for the revised system after receiving and
responding to public
[[Page 66840]]
comments (72 FR 42486). In that rule, we also finalized the evaluation
criteria for the designation of surgical procedures as office-based (72
FR 42512). Therefore, the evaluation criteria and payment policy for
office-based procedures were not open to comment in the CY 2008 OPPS/
ASC proposed rule and we are not addressing additional comments in this
final rule with comment period.
Based on the public comments we received, we reexamined the
relevant data and clinical characteristics for each of the 15
procedures for which we received comments. Although, as the commenters
asserted, many of the 15 procedures are performed in physicians'
offices somewhat less than 50 percent of the time, our final policy for
designating ASC procedures as office-based allows us to take into
account the clinical characteristics, volume, and utilization data of
related HCPCS codes to supplement our consideration of data specific to
the codes of interest (72 FR 42512). Our review of the clinical
characteristics of the 15 procedures and volume and utilization data
for them and for similar procedures convinced us that our proposed
designations are correct for all but 1 of the procedures.
We are not finalizing our proposal to designate CPT code 46505
(Chemodenervation of internal anal sphincter) as an office-based
procedure. After reviewing the currently available utilization data for
this code and related codes, we believe this procedure is not
predominantly performed in physicians' offices and should maintain the
``G2'' payment indicator assigned to CPT code 46505 in the August 2,
2007 revised ASC payment system final rule for CY 2008.
In the case of CPT code 28890, although Medicare utilization data
show that over 70 percent of CY 2006 utilization occurred in the
physician's office, we are persuaded by commenters that this code was
new for CY 2006 and some providers may have confused this service with
the performance of low energy ESWT procedures. Stakeholders have
explained to us that, although the physician utilization data may
reflect that the service is performed mainly in the physician's office,
this finding could be due to miscoding of low energy procedures that
use only local anesthesia, rather than correct use of the CPT code
28890 to report high energy procedures that require anesthesia other
than local. Nevertheless, we do not believe it would be appropriate to
consider CPT code 28890 to be nonoffice-based for CY 2008 based on the
significant utilization reported for the physician's office setting.
Under the MPFS, this service has been priced specifically for
performance in the office; therefore, we believe it can be
appropriately performed in the physician's office. Furthermore, we note
that there is an existing Category III CPT code for reporting the low
energy services, specifically CPT code 0019T (Extracorporeal shock wave
involving musculoskeletal system, not otherwise specified, low energy),
for which the facility resources would be expected to differ.
Nevertheless, given the concerns over the utilization data in the
code's first year of use, while we follow the utilization of CPT code
28890 for another year, we will maintain the office-based designation
of this procedure as temporary to allow for the possibility that coding
for high energy ESWT for the plantar fascia will improve as providers
gain more experience with the CPT code. This designation is indicated
with an asterisk in Table 52 below. When we have sufficient data, we
will either propose to finalize the office-based designation of the
service or propose to change its payment indicator to ``G2'' as a
nonoffice-based procedure.
While we are aware of the existence of CPT codes 0101T and 0102T
for high energy ESWT for body areas other than treatment of the plantar
fascia, utilization data available for the proposed rule did not
support a proposal to designate those codes as office-based for CY
2008. Furthermore, these services have no MPFS nonfacility PE RVUs at
this time. Therefore, a payment limitation based on the MPFS
nonfacility PE RVUs could not be applied. We will review their
utilization data for the next ASC annual update.
The procedures proposed for designation as office-based and their
final CY 2008 payment indicators are listed in Table 52 below. All
office-based designations are final, with the exception of the
designation of CPT code 28890 as office-based, which will remain
temporary until we have adequate utilization data to support a proposal
to remove it from the office-based list or finalize the office-based
designation.
Table 52.--CY 2008 Final New Designations of ASC Covered Surgical Procedures Proposed as Office-Based
----------------------------------------------------------------------------------------------------------------
HCPCS code (+ indicates Final CY 2008 payment
procedures commenters Proposed CY 2008 payment indicator (* if
recommended not be designated Short descriptor indicator designation is temporary
as office-based) for CY 2008)
----------------------------------------------------------------------------------------------------------------
24640+........................ Treat elbow dislocation.. P3........................ P3
26641+........................ Treat thumb dislocation.. P2........................ P2
26670+........................ Treat hand dislocation... P2........................ P2
26700+........................ Treat knuckle dislocation P2........................ P2
26775+........................ Treat finger dislocation. P3........................ P3
28630+........................ Treat toe dislocation.... P3........................ P3
28660+........................ Treat toe dislocation.... P3........................ P3
28890+........................ High energy eswt, plantar P3........................ P3*
fascia.
29035......................... Application of body cast. P2........................ P2
29305......................... Application of hip cast.. P2........................ P2
29325......................... Application of hip casts. P2........................ P2
29505+........................ Application, long leg P3........................ P3
splint.
29515+........................ Application lower leg P3........................ P3
splint.
36469+........................ Injection(s), spider R2........................ R2
veins.
46505+........................ Chemodenervation anal P3........................ G2
misc.
62292......................... Injection into disk R2........................ R2
lesion.
64447+........................ Nblock inj fem, single... R2........................ R2
64650+........................ Chemodenerv, eccrine P3........................ P3
glands.
[[Page 66841]]
64653+........................ Chemodenerv, eccrine P3........................ P3
glands.
----------------------------------------------------------------------------------------------------------------
We did not receive any public comments regarding our proposal to
maintain as temporary the office-based designation for CPT codes 0099T
(Implantation of intrastromal corneal ring segments); 0124T
(Conjunctival incision with posterior juxtascleral placement of
pharmacological agent (does not include supply of medication); and
55876 (Placement of interstitial device(s) for radiation therapy
guidance (e.g., fiducial markers, dosimeter), prostate (via needle, any
approach), single or multiple) or our proposal to make permanent the
designation of CPT code 36598 (Contrast injection(s) for radiologic
evaluation of existing central venous access device, including
fluoroscopy, image documentation and report) as office-based. Although
we received public comments about the proposed policy to package more
procedures for CY 2008 under the OPPS, we did not receive any specific
public comments regarding the designation of CPT code 58110
(Endometrial sampling (biopsy) with or without endocervical sampling
(biopsy), without cervical dilation, any method (separate procedure))
as packaged for CY 2008.
Therefore, we are finalizing our CY 2008 proposals, without
modification, to maintain the temporary office-based designations of
CPT codes 0099T, 0124T, and 55876, the permanent office-based
designation of CPT code 36598, and the packaged status of CPT code
58110. The procedures and the final payment indicators for CY 2008 are
displayed below in Table 53.
Displayed in Table 53 are the new CY 2008 HCPCS codes (excluding
renumbered codes) to which we have assigned temporary office-based
payment indicators. Those designations are temporary and are open to
comment during the 60-day comment period for this final rule with
comment period. We will respond to public comments on those
designations in the OPPS/ASC final rule with comment period for CY
2009.
Table 53.--CY 2008 Payment Indicators for Procedures Assigned Temporary
Office-Based Payment Indicators in the August 2, 2007 Revised ASC
Payment System Final Rule
------------------------------------------------------------------------
Final CY 2008 ASC
payment indicator (* if
HCPCS code Short descriptor designation is
temporary for CY 2008)
------------------------------------------------------------------------
0099T.............. Implant corneal ring...... R2*
0124T.............. Conjunctival drug R2*
placement.
36598.............. Inj w/fluor, eval cv P3
device.
55876.............. Place rt device/marker, P3*
pros.
58110.............. Bx done w/colposcopy add- N1
on.
------------------------------------------------------------------------
Table 54.--CY 2008 Payment Indicators for New CY 2008 ASC Covered
Surgical Procedures Assigned Temporary Office-Based Payment Indicators
on an Interim Final Basis
------------------------------------------------------------------------
Final CY 2008 ASC
payment indicator (* if
HCPCS code Short descriptor designation is
temporary for CY 2008)
------------------------------------------------------------------------
21073.............. Mnpj of tmj w/anesth...... P3*
67229.............. Tr retinal les preterm inf R2*
68816.............. Probe nl duct w/balloon... P3*
------------------------------------------------------------------------
c. Changes in Designation of Covered Surgical Procedures as Device-
Intensive
As explained in section XVI.C.1.c.(3) of this final rule with
comment period, we adopted a modified payment methodology for
calculating the ASC payment rates for ASC covered surgical procedures
that are assigned to the subset of device-dependent APCs under the OPPS
with a device offset percentage greater than 50 percent under the OPPS
to ensure that payment for the procedure is adequate to provide
packaged payment for the high-cost implantable devices used in those
procedures. In the August 2, 2007 revised ASC payment system final
rule, we identified 24 procedures that were on the CY 2007 ASC list of
covered surgical procedures that would be subject to this policy, as
well as 15 new
[[Page 66842]]
ASC covered surgical procedures for CY 2008, to which we expected the
final policy to apply.
As a result of the proposed CY 2008 reconfiguration of several
device-dependent APCs under the OPPS and the proposed updated APC
device offset percentages in the CY 2008 OPPS/ASC proposed rule, we
proposed to designate as device-intensive for ASC payment in CY 2008 an
additional 10 ASC covered surgical procedures. We also proposed to
remove 4 procedures from their estimated designation as device-
intensive because we proposed to recognize CPT codes instead of Level
II HCPCS codes for ICD implantation procedures as discussed in section
III.D.1.c. of this final rule with comment period. We proposed to
assign payment indicators ``H8'' or ``J8,'' as appropriate, to the
covered surgical procedures identified as device-intensive so that
payment would be made consistent with our final revised ASC payment
system payment policy.
We received a number of public comments on our proposal for payment
of device-intensive procedures in ASCs for CY 2008. A summary of the
public comments and our responses follow.
Comment: Most commenters were generally pleased with the final
payment policy, but several commenters requested that CMS apply the
device-intensive payment methodology to either all ASC covered
procedures assigned to device-dependent APCs or to those assigned to
APCs with a lower offset percentage threshold than 50 percent so that
more ASC covered surgical procedure rates would be calculated using the
device-intensive methodology. Many commenters requested that covered
procedures for which ASCs billed separately for implantable prosthetic
devices under the CY 2007 payment system also be treated like those
procedures CMS has identified as device-intensive, even though the
device offset percentage under the OPPS for the procedures may be less
than the 50 percent threshold. Specifically, some of the commenters
requested that the ASC payment rates for the CPT codes listed in Table
55 of this final rule with comment period be calculated as device-
intensive procedure rates, that they be allowed to be paid at revised
ASC rates without being subject to the transitional ASC rates for CYs
2008, 2009, and 2010 or that the device cost be added to the CY 2007
ASC rate which would be used to calculate the transitional rate. The
commenters stated that the payment rates during the transition period
for procedures like these, that require high cost implantable products,
are too low for ASCs to be able to continue to provide the services.
The commenters advised CMS to monitor the migration of these
procedures, and others like them, into the higher cost HOPD setting
during the first years under the revised ASC payment system.
Table 55.--Specific Procedures for Which Commenters Requested CY 2008
Payment Rates That Fully Recognize the Costs of Implantable Devices
------------------------------------------------------------------------
Final CY 2008 payment
HCPCS code Long descriptor indicator
------------------------------------------------------------------------
51715.............. Endoscopic injection of A2
implant material into the
submucosal tissues of the
urethra and/or bladder
neck.
57288.............. Sling operation for stress A2
incontinence (e.g.,
fascia or synthetic).
65105.............. Enucleation of eye; within A2
implant, muscles attached
to implant.
65140.............. Insertion of ocular A2
implant secondary; after
enucleation, muscles
attached to implant.
65155.............. Reinsertion of ocular A2
implant; with use of
foreign material for
reinforcement and/or
attachment of muscles to
implant.
65770.............. Keratoprosthesis.......... A2
66180.............. Aqueous shunt to A2
extraocular reservoir
(e.g., Molteno, Schocket,
Denver-Krupin).
67912.............. Correction of A2
lagophthalmos, with
implantation of upper
eyelid lid load (e.g.,
gold weight).
------------------------------------------------------------------------
Response: We appreciate the information shared by the commenters
and their suggestions for payment policies for ASC procedures included
on the CY 2007 ASC list for which separate payment is currently made
for implantable prosthetic devices. Nonetheless, the policy for payment
of these procedures was made final in the August 2, 2007 revised ASC
payment system final rule after we received and addressed public
comments (72 FR 42503). Only two of the procedures cited by the
commenter, CPT codes 57288 and 65770, are assigned to device-dependent
APCs under the OPPS, and neither APC has a device offset percentage
above 50 percent. Payment will be made for all of these services at the
transitional rates for CY 2008, based on their status as nondevice-
intensive procedures.
Comment: Several commenters suggested that CMS should create
additional payment policies to provide special payment for new
technologies, procedures on the CY 2007 ASC list of covered procedures
that never were provided in ASCs, and previous pass-through devices.
The commenters were concerned about procedures included on the CY 2007
ASC list that are not currently provided in ASCs. They stated that the
very low payment amounts under the existing system precluded the
performance of those procedures and, therefore, the procedures should
not be subject to the transitional payment rates. In effect, the
commenters explained, those procedures are new to the ASC list for CY
2008 and as such, they should be allowed to bypass the transition to be
paid at the revised ASC rates in CY 2008. For example, one commenter
suggested that CPT code 55873 (Cryosurgical ablation of the prostate
(includes ultrasonic guidance for interstitial cryosurgical probe
placement)), a device-intensive procedure, should not be subject to the
transition at all because it was not performed in ASCs prior to CY
2008, even though it was included on the ASC list of covered surgical
procedures beginning in CY 2005.
The commenter who suggested additional policies for new technology
and pass through payments under the ASC payment system stated that
adequate payment for newer advanced technologies in the most
appropriate setting would ensure beneficiary access to optimum care.
Response: The payment policies for the revised ASC payment system
to be implemented January 1, 2008 were finalized in the August 2, 2007
revised ASC payment system final rule after we received and addressed
public comments (72 FR 42493). With respect to device-intensive
procedures such as CPT codes 55873 that were on the CY 2008 ASC list,
the device portion of the payment is not subject to the transition,
while the payment portion will receive
[[Page 66843]]
transitional payment. The final policies do not incorporate a
methodology to exclude from the transitional payment any procedures on
the CY 2007 ASC list. We will not consider any changes to those
policies in this final rule with comment period.
The final policies for the revised ASC payment system will pay
separately for those implantable devices with pass-through status under
the OPPS and will pay for new technology surgical procedures described
by Category III CPT codes or Level II HCPCS codes that crosswalk
directly or are clinically similar to established procedures already on
the ASC list of covered surgical procedures. In this way, we believe
these policies will serve to appropriately incorporate payment for new
technologies under the revised ASC payment system.
In summary, after consideration of the public comments received, we
are implementing, without modification, the proposal to designate the
procedures listed in Table 56 as device-intensive ASC covered surgical
procedures for CY 2008, based on their CY 2008 final assignments to
APCs under the OPPS that are device-dependent and which have device
offset percentages greater than 50 percent. We are not making any
changes to our final ASC policies related to the designation of device-
intensive procedures, transitional payment for procedures covered in
the ASC setting in CY 2007, or payment for new technologies.
Table 56.--ASC Covered Surgical Procedures Designated as Device-Intensive for CY 2008
----------------------------------------------------------------------------------------------------------------
CY 2008 device-
CY 2008 OPPS dependent APC
HCPCS code Short descriptor APC offset
percentage
----------------------------------------------------------------------------------------------------------------
33206.................................. Insertion of heart pacemaker........... 0089 72.99
33207.................................. Insertion of heart pacemaker........... 0089 72.99
33208.................................. Insertion of heart pacemaker........... 0655 74.62
33210.................................. Insertion of heart electrode........... 0106 56.25
33211.................................. Insertion of heart electrode........... 0106 56.25
33212.................................. Insertion of pulse generator........... 0090 76.01
33213.................................. Insertion of pulse generator........... 0654 77.13
33214.................................. Upgrade of pacemaker system............ 0655 74.62
33216.................................. Insert lead pace-defib, one............ 0106 56.25
33217.................................. Insert lead pace-defib, dual........... 0106 56.25
33224.................................. Insert pacing lead & connect........... 0418 82.52
33225.................................. Lventric pacing lead add-on............ 0418 82.52
33240.................................. Insert pulse generator................. 0107 89.11
33249.................................. Eltrd/insert pace-defib................ 0108 89.24
33282.................................. Implant pat-active ht record........... 0680 73.15
36566.................................. Insert tunneled cv cath................ 0625 58.88
53440.................................. Male sling procedure................... 0385 51.56
53444.................................. Insert tandem cuff..................... 0385 51.56
53445.................................. Insert uro/ves nck sphincter........... 0386 63.53
53447.................................. Remove/replace ur sphincter............ 0386 63.53
54400.................................. Insert semi-rigid prosthesis........... 0385 51.56
54401.................................. Insert self-contd prosthesis........... 0386 63.53
54405.................................. Insert multi-comp penis pros........... 0386 63.53
54410.................................. Remove/replace penis prosth............ 0386 63.53
54416.................................. Remv/repl penis contain pros........... 0386 63.53
55873.................................. Cryoablate prostate.................... 0674 60.27
61885.................................. Insrt/redo neurostim 1 array........... 0039 82.73
61886.................................. Implant neurostim arrays............... 0315 86.15
62361.................................. Implant spine infusion pump............ 0227 80.73
62362.................................. Implant spine infusion pump............ 0227 80.73
63650.................................. Implant neuroelectrodes................ 0040 56.27
63655.................................. Implant neuroelectrodes................ 0061 60.60
63685.................................. Insrt/redo spine n generator........... 0222 84.86
64553.................................. Implant neuroelectrodes................ 0225 80.57
64555.................................. Implant neuroelectrodes................ 0040 56.27
64560.................................. Implant neuroelectrodes................ 0040 56.27
64561.................................. Implant neuroelectrodes................ 0040 56.27
64565.................................. Implant neuroelectrodes................ 0040 56.27
64573.................................. Implant neuroelectrodes................ 0225 80.57
64575.................................. Implant neuroelectrodes................ 0061 60.60
64577.................................. Implant neuroelectrodes................ 0061 60.60
64580.................................. Implant neuroelectrodes................ 0061 60.60
64581.................................. Implant neuroelectrodes................ 0061 60.60
64590.................................. Insrt/redo pn/gastr stimul............. 0222 84.86
69930.................................. Implant cochlear device................ 0259 82.94
----------------------------------------------------------------------------------------------------------------
2. Changes for Identification of Covered Ancillary Services
In the August 2, 2007 revised ASC payment system final rule, we set
forth our policy to make separate ASC payments for certain ancillary
services, for which separate payment is made under the OPPS, when they
are provided integral to ASC covered surgical procedures. Under the
revised ASC payment system, we exclude from the scope of ASC facility
services, for which payment is packaged into the ASC payment for the
covered surgical procedure, the following ancillary
[[Page 66844]]
services that are integral to a covered surgical procedure:
brachytherapy sources; certain implantable items that have pass-through
status under the OPPS; certain items and services that we designate as
contractor-priced, including, but not limited to, procurement of
corneal tissue; certain drugs and biologicals for which separate
payment is allowed under the OPPS; and certain radiology services for
which separate payment is allowed under the OPPS. These covered
ancillary services are specified in Sec. 416.164(b) and fall within
the scope of ASC services, so they are eligible for separate ASC
payment.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42788), we proposed to
make changes to the list of covered ancillary services eligible for
separate ASC payment, as proposed in Addendum BB to that proposed rule,
to comport with their proposed treatment under the OPPS according to
the final payment policies of the revised ASC payment system, and to
add new Category III CPT code 0182T (High dose rate electronic
brachytherapy, per fraction), as discussed in section XVI.D.2. of this
final rule with comment period. Accordingly, we are finalizing changes
to the list of covered ancillary services eligible for ASC payment in
Addendum BB of this final rule with comment period to reflect the
policies finalized for the CY 2008 OPPS and to add Category III CPT
code 0182T to the list of covered ancillary services.
F. Payment for Covered Surgical Procedures and Covered Ancillary
Services
1. Payment for Covered Surgical Procedures
a. Update to Payment Rates
Our final payment policy for covered surgical procedures under the
revised ASC payment system is described in section XVI.C. of this final
rule with comment period. In the CY 2008 OPPS/ASC proposed rule (72 FR
42788), for CY 2008, we proposed to update payment for procedures with
payment indicators ``G2'' and ``A2,'' using CY 2006 utilization data.
We did not propose to make any changes to the final policies
established in the August 2, 2007 revised ASC payment system final rule
related to the methodology for developing the relative payment weights
and rates. The differences in the payment rates for covered surgical
procedures with ``G2'' and ``A2'' payment indicators, reflected in
Addendum AA to the proposed rule, compared with the August 2, 2007
revised ASC payment system final rule, were due to our use of updated
CY 2006 utilization data, proposed payment policy changes for the CY
2008 OPPS, including APC reassignments and changes to packaged
services, and the proposed OPPS update factor.
We also proposed to update the payment amounts for the office-based
procedures in the CY 2008 OPPS/ASC proposed rule. Using the most recent
available MPFS and OPPS data, including the proposed CY 2008 rates, we
compared the estimated CY 2008 rate for each of the office-based
procedures calculated according to the standard methodology of the
revised ASC payment system and to the MPFS nonfacility PE RVUs to
determine which is the lower payment amount that, therefore, is the
rate we proposed for payment of the procedure according to the final
policy of the revised ASC payment system. The proposed update to the
rates resulted in changes to the payment indicators, as well as the
rates, for several of the office-based procedures. For example, a
procedure with payment indicator ``P2'' in the August 2, 2007 revised
ASC payment system final rule may have been assigned payment indicator
``P3'' in the CY 2008 OPPS/ASC proposed rule, depending on the outcome
of that rate comparison.
In addition, we proposed to update the payment amounts for the
device intensive procedures in the proposed rule, based on the CY 2008
OPPS proposal and updated OPPS claims data.
We received many public comments on the proposed CY 2008 payment
rates for covered surgical procedures. A summary of the public comments
and our responses follow.
Comment: Many commenters were concerned that the proposed ASC rates
for covered surgical procedures that require expensive equipment and
single-use, disposable supplies would not be adequate to cover the
costs, especially during the first 3 years of the revised payment
system. The commenters offered a number of suggestions, such as
establishing a class of procedures that are ``equipment-intensive'' for
which an alternate payment methodology similar to that for ``device-
intensive'' procedures could be used to set rates, to address their
concern that payments, even at the revised ASC rates, would be
inadequate for procedures like lithotripsy (CPT code 50590
(Lithotripsy, extracorporeal shock wave)), which requires equipment
that costs the same wherever the procedure is performed. Other
commenters suggested that procedures that include use of expensive
single-use supplies be paid at the fully implemented rate beginning in
CY 2008.
Response: We appreciate the commenters' concerns. However, the
payment methodologies for the revised ASC payment system were made
final in the revised ASC payment system final rule published on August
2, 2007 after we received and addressed public comments. As explained
in that final rule (72 FR 42503), we believe that it would not be
appropriate to provide separate payment for aspects of procedures (for
example, implantable prosthetics or equipment) that are packaged into
the ASC payment rates for the procedures under the revised payment
system.
Comment: None of the commenters opposed updating the payment rates
for covered surgical procedures by using the most recent available MPFS
and OPPS data. However, several commenters asked that CMS review the
proposed payment rate for CPT code 64517 (Injection, anesthetic agent;
superior hypogastric plexus) because they believed that the proposed CY
2008 rate included in Addendum AA to the proposed rule might be
erroneous.
Response: We reviewed the proposed rate for CPT code 64517, which
is assigned payment indicator ``A2,'' and found that the rate for CY
2008 displayed in Addendum AA of the proposed rule was correct. The
method for calculating the rate for procedures with ``A2'' payment
indicator, like CPT code 64517, is displayed in Table 57. As can be
seen in the table, the proposed rate of $178.12 for CPT code 64517
included in the CY 2008 OPPS/ASC proposed rule Addendum AA was correct.
We believe the example presented is helpful in understanding the
transitional payment rate calculations.
[[Page 66845]]
Table 57.--Sample Calculation of Year One (CY 2008) National Unadjusted
Transitional Payment Rate for Covered Surgical Procedures Assigned
Payment Indicator ``A2''
------------------------------------------------------------------------
CY 2008 rate
Steps in calculation of year calculation for CY 2008 proposed
one (CY 2008) transitional procedures with rule calculation for
ASC payment rate payment indicator CPT code 64517
``A2''
------------------------------------------------------------------------
Step 1...................... Multiply transition 0.75 x $139 =
year one CY 2007 $104.25.
ASC portion of
blended rate by the
CY 2007 ASC rate.
Step 2...................... Calculate CY 2008 7.1370 x $41.400 =
fully implemented $295.4718.
ASC rate by
multiplying ASC
relative weight by
ASC conversion
factor.
Step 3...................... Multiply transition 0.25 x $295.4718 =
year one CY 2008 $73.86795.
portion of blended
rate by the fully
implemented ASC
rate.
Step 4...................... Add the 75 percent $104.25 + $73.86795
and 25 percent = $178.11795 which
amounts of the rounds to $178.12.
blended rate to
equal the year one
(CY 2008)
transitional rate;
round to two
decimal places.
------------------------------------------------------------------------
Therefore, after consideration of all public comments received, we
are implementing our policy to update the CY 2008 ASC rates using the
most recently available OPPS and MPFS data. The ASC national unadjusted
rates for all covered surgical procedures are displayed in Addendum AA
to this final rule with comment period.
b. Payment Policies When Devices Are Replaced at No Cost or With Credit
(1) Policy When Devices Are Replaced at No Cost or With Full Credit
Our final ASC policy with regard to payment for costly devices
implanted in ASCs is fully consistent with the current OPPS policy. The
ASC policy includes adoption of the OPPS policy for payment to
providers when a device is replaced without cost or with full credit
for the cost of the device being replaced, for those ASC covered
surgical procedures that are assigned to APCs under the OPPS to which
this policy applies. In the case of no cost or full credit cases under
the OPPS, we reduce the APC payment to the hospital by the device
offset amount that we estimate represents the cost of the device.
Therefore, in accordance with the OPPS policy implemented in CY 2007,
and the ASC policy as finalized in the August 2, 2007 revised ASC
payment system final rule, beginning in CY 2008, we reduce the amount
of payment made to ASCs for certain covered surgical procedures when
the necessary device is furnished without cost to the ASC or the
beneficiary or with a full credit for the cost of the device being
replaced. We provide the same amount of payment reduction based on the
device offset amount in ASCs that would apply under the OPPS for
performance of those procedures under the same circumstances.
Specifically, when a procedure that is listed in Table 58 below is
performed in an ASC and the case involves implantation of a no cost or
full credit device listed in Table 59, the ASC must report the HCPCS
``FB'' modifier on the line with the covered surgical procedure code to
indicate that an implantable device in Table 59 was furnished without
cost. The devices listed in Table 59 are the same devices to which the
policy applies under the OPPS, and the procedures listed in Table 58
are those ASC covered surgical procedures assigned to APCs under the
OPPS to which the policy applies.
As finalized in the August 2, 2007 revised ASC payment system final
rule (72 FR 42506), when the ``FB'' modifier is reported with a
procedure code that is listed in Table 58, the contractor reduces the
ASC payment by the amount of payment that we attributed to the device
when the ASC payment rate was calculated. The reduction of ASC payment
in this circumstance is necessary to pay appropriately for the covered
surgical procedure being furnished by the ASC.
(2) Policy When Implantable Devices Are Replaced with Partial Credit
Consistent with our CY 2008 OPPS proposal discussed in section
IV.A.3. of this final rule with comment period, we proposed to reduce
the ASC payment by one half of the device offset amount for certain
surgical procedures into which the device cost is packaged, when an ASC
receives a partial credit toward replacement of an implantable device
(72 FR 42788). We proposed that the partial payment reduction would
apply to covered surgical procedures in which the amount of the device
credit is greater than or equal to 20 percent of the cost of the new
replacement device being implanted. We also proposed to base the
beneficiary's coinsurance on the reduced ASC payment rate so that the
beneficiary shares the benefit of the ASC's reduced costs.
We have no OPPS data to empirically determine by how much we should
reduce the payment for ASC surgical procedures into which the costs of
these devices are packaged. Device manufacturers and hospitals have
told us that a common scenario is that, if a device fails 3 years after
implantation, the hospital would receive a 50 percent credit towards a
replacement device. We do not believe that hospitals reduce their
device charges to reflect the credits that may have been received, so
the lower facility costs associated with the partial credit scenarios
would likely not be reflected in our proposed OPPS rates for these
device-dependent procedures. Therefore, we proposed under the OPPS to
reduce the payment for the relevant device dependent APCs and, under
the revised ASC payment system, to reduce the payment for those ASC
covered surgical procedures assigned to those APCs under the OPPS by
half of the reduction that applies when the hospital or ASC receives a
device without cost or receives a full credit for a device being
replaced. That is, we proposed to reduce the payments by half of the
offset amount that represents the cost of the device packaged into the
procedure payment. In the absence of OPPS claims data on which to base
a reduction factor, but taking into consideration what we have been
told is common industry practice, we believe that reducing the amount
of payment for the device dependent APC and the related ASC covered
surgical procedure by half of the estimated cost of the device
packaging represents a reasonable reduction in these cases. We listed
the ASC procedures to which this proposed policy would apply in Table
64 of the CY 2008 OPPS/ASC proposed rule (72 FR 42790).
Moreover, we proposed to take this reduction only when the credit
is for 20 percent or more of the cost of the new replacement device, so
that the
[[Page 66846]]
reduction is not taken in cases in which more than 80 percent of the
cost of the replacement device has been incurred by the facility. If
the partial credit is less than 20 percent of the cost of the new
replacement device, we believe that reducing the payment for the device
implantation procedure by 50 percent of the packaged device cost would
provide too low a payment for necessary device replacement procedures.
Accordingly, we proposed that the new HCPCS partial credit modifier
must be reported for cases in which the device credit is equal to or
greater than 20 percent of the cost of the new replacement device if
the device was listed in Table 65 of the CY 2008 OPPS/ASC proposed rule
with comment period (72 FR 42790). We selected these devices because
they have substantial costs and because each device is implanted in one
beneficiary at least temporarily and, therefore, can be associated with
an individual beneficiary.
The proposed policy related to partial device credits applies to
the same devices and procedures to which our policy governing payment
when the device is furnished to the ASC without cost or with full
credit applies. We believe that this policy is a logical extension of
our established policy regarding reduction of the ASC payment in cases
in which the facility furnishes the device without cost or with a full
credit to the ASC and ensures that beneficiary and Medicare payments
are appropriate and consistent with costs incurred by ASCs.
This partial device credit policy that we proposed would enhance
our ability to track the replacement of these implantable medical
devices and may enable us to identify patterns of device failure or
limited longevity early in their natural history so that appropriate
strategies to reduce future problems for our beneficiaries may be
developed. We also are mindful of the opportunity to use our claims
history data to promote high quality medical care with regard to the
devices and the services in which they are used. Collecting data on a
wider set of device replacements under full and partial credit
situations in all sites of outpatient surgery, including ASCs, would
assist in developing comprehensive summary data, not just a subset of
data related to devices replaced without cost or with a full credit to
facilities.
Comment: As described in section IV.A.3. of this final rule with
comment period, we received several public comments on our proposal to
reduce payment if an expensive implantable device is replaced and the
facility receives a partial credit toward the cost of the replacement
device. Principally, the commenters agreed that neither Medicare nor
beneficiaries should have to pay based on a device's full cost when the
hospital receives a substantial credit from the manufacturer for that
device and supported the premise underpinning the proposed policy that
hospitals' charges and the payment rates based on those charges
currently do not reflect partial credits for replaced devices. However,
the commenters argued that CMS should raise the partial credit
threshold to which this policy would apply to 50 percent of the cost of
the replacement device, consistent with the policy CMS recently
implemented for devices replaced with partial credit for services paid
under the FY 2008 IPPS. Many commenters also urged adoption of the same
billing options that are available under the IPPS for billing devices
replaced with partial credit. Specifically, they requested that
hospitals and ASCs be allowed to: (1) Submit the claims for replacement
devices immediately without the HCPCS modifier signifying partial
credit for a replacement device and later, if a credit is ultimately
issued, submit a claim adjustment with the appropriate coding; or (2)
hold the claim until a credit determination is made. We refer readers
to section IV.A.3. of this final rule with comment period for a more
detailed summary of the comments we received on this proposal.
Response: After consideration of the public comments received, we
are adopting a modified policy for certain procedures involving partial
credit for a replacement device. Consistent with the final CY 2008 OPPS
policy described in detail in section IV.A.3. of this final rule with
comment period, and the recently implemented FY 2008 IPPS policy, we
will reduce the ASC payment for implantation procedures listed in Table
58 below by one half of the device offset that would be applied if a
replacement device were provided at no cost or with full credit, if the
credit is 50 percent or more of the replacement device cost, rather
than the proposed 20 percent. We believe that payment policies across
hospital payment systems, including the OPPS, the IPPS, and the revised
ASC payment system, should align whenever possible and appropriate, as
is true in this case. We refer readers to section IV.A.3. of this final
rule with comment period for a more detailed discussion of our decision
to implement a 50 percent rather than 20 percent threshold to which the
partial credit policy will apply.
ASCs will be instructed to append the new ``FC'' modifier to the
HCPCS code for the procedure in which the device was inserted on claims
when the device that was replaced with partial credit under warranty,
recall, or field action is one of the devices in Table 59 below (ASCs
should not append the modifier to the HCPCS procedure code if the
device is not listed in Table 59 below). The partial credit adjustment
will be made to the national unadjusted rate, similar to what occurs
when a device is replaced at full credit or with no cost, and
beneficiary coinsurance will be adjusted to reflect the reduced payment
amount.
As discussed in section IV.A.3. of this final rule with comment
period, we understand commenters' concerns about potential delays that
could occur while a returned device is being evaluated to determine
whether and by how much a credit will be applied. In order to report
that they received a partial credit of 50 percent or more of the cost
of a replacement device, ASCs will have the option of either: (1)
Submitting the claim for the device replacement procedure to their
Medicare contractor after the procedure's performance but prior to
manufacturer acknowledgment of credit for a replacement device, and
subsequently contacting the contractor regarding a claims adjustment
once the credit determination is made; or (2) holding the claim for the
device replacement procedure until a determination is made by the
manufacturer on the partial credit and submitting the claim with the
``FC'' modifier appended to the implantation procedure HCPCS code if
the partial credit is 50 percent or more of the cost of the replacement
device. If choosing the first billing option, to request a claim
adjustment once the credit determination is made, ASCs should keep in
mind that the initial Medicare payment for the procedure involving the
replacement device is conditional and subject to adjustment. These
billing instructions are consistent with instructions issued for
billing under the IPPS and OPPS. We will issue additional billing
instructions in a separate transmittal after publication of this final
rule with comment period.
In summary, after consideration of the public comments received, we
are finalizing a modified policy for certain procedures involving
partial credit for a replacement device. Specifically, we will reduce
the payment for implantation procedures listed in Table 58 below by one
half of the device offset that would be applied if a replacement device
were provided at no cost or with full credit, if the credit is 50
percent or more of the replacement device cost. In order to implement
this policy, we will require ASCs to report the new modifier
[[Page 66847]]
``FC'' in all cases in which the ASC receives a partial credit toward
the replacement of a medical device listed in Table 59 below when used
in a surgical procedure listed in Table 58 for which the ASC received
at least a 50 percent credit. In order to report that they received a
partial credit of 50 percent or more of the cost of a replacement
device, ASCs will have the option of either: (1) Submitting the claim
for the device replacement procedure to their Medicare contractor after
the procedure's performance but prior to manufacturer acknowledgment of
credit for a replacement device, and subsequently contacting the
contractor regarding a claims adjustment once the credit determination
is made; or (2) holding the claim for the device replacement procedure
until a determination is made by the manufacturer on the partial credit
and submitting the claim with the ``FC'' modifier appended to the
implantation procedure HCPCS code if the partial credit is 50 percent
or more of the cost of the replacement device. Beneficiary coinsurance
will be based on the reduced payment amount.
Table 58.--Adjustments to Payments for ASC Covered Surgical Procedures in CY 2008 in Cases of Devices Reported
Without Cost or for Which Full or Partial Credit is Received
----------------------------------------------------------------------------------------------------------------
50 percent
CY 2008 CY 2008 of CY 2008
HCPCS code Short descriptor OPPS APC APC title OPPS offset OPPS offset
percentage percentage
----------------------------------------------------------------------------------------------------------------
61885................. Insrt/redo neurostim 1 0039 Level I Implantation of 82.73 41.37
array. Neurostimulator.......
64590................. Insrt/redo perph n
generator.
----------------------------------------------------------------------------------------------------------------
63650................. Implant neuroelectrodes. 0040 Percutaneous 56.27 28.14
Implantation of
Neurostimulator
Electrodes, Excluding
Cranial Nerve.
64555................. Implant neuroelectrodes.
64560................. Implant neuroelectrodes.
64561................. Implant neuroelectrodes.
64565................. Implant neuroelectrodes.
----------------------------------------------------------------------------------------------------------------
63655................. Implant neuroelectrodes. 0061 Laminectomy or Incision 60.60 30.30
for Implantation of
Neurostimulator
Electrodes, Excluding
Cranial Nerve.
64575................. Implant neuroelectrodes.
64577................. Implant neuroelectrodes.
64580................. Implant neuroelectrodes.
64581................. Implant neuroelectrodes.
----------------------------------------------------------------------------------------------------------------
33206................. Insertion of heart 0089 Insertion/Replacement 72.99 36.50
pacemaker. of Permanent Pacemaker
and Electrodes.
----------------------------------------------------------------------------------------------------------------
33207................. Insertion of heart
pacemaker.
----------------------------------------------------------------------------------------------------------------
33212................. Insertion of pulse 0090 Insertion/Replacement 76.01 38.01
generator. of Pacemaker Pulse
Generator.
----------------------------------------------------------------------------------------------------------------
33210................. Insertion of heart 0106 Insertion/Replacement/ 56.25 28.13
electrode. Repair of Pacemaker
and/or Electrodes.
33211................. Insertion of heart
electrode.
33216................. Insert lead pace-defib,
one.
33217................. Insert lead pace-defib,
dual.
----------------------------------------------------------------------------------------------------------------
33240................. Insert pulse generator.. 0107 Insertion of 89.11 44.56
Cardioverter-
Defibrillator.
----------------------------------------------------------------------------------------------------------------
33249................. Eltrd/insert pace-defib. 0108 Insertion/Replacement/ 89.24 44.62
Repair of Cardioverter-
Defibrillator Leads.
----------------------------------------------------------------------------------------------------------------
63685................. Insrt/redo spine n 0222 Implantation of 84.86 42.43
generator. Neurological Device.
----------------------------------------------------------------------------------------------------------------
64553................. Implant neuroelectrodes. 0225 Implantation of 80.57 40.29
Neurostimulator
Electrodes, Cranial
Nerve.
64573................. Implant neuroelectrodes.
----------------------------------------------------------------------------------------------------------------
62361................. Implant spine infusion 0227 Implantation of Drug 80.73 40.37
pump. Infusion Device.
62362................. Implant spine infusion
pump.
----------------------------------------------------------------------------------------------------------------
69930................. Implant cochlear device. 0259 Level VI ENT Procedures 82.94 41.47
----------------------------------------------------------------------------------------------------------------
61886................. Implant neurostim arrays 0315 Level II Implantation 86.15 43.08
of.
Neurostimulator.......
----------------------------------------------------------------------------------------------------------------
53440................. Male sling procedure.... 0385 Level I Prosthetic 51.56 25.78
Urological Procedures.
53444................. Insert tandem cuff......
54400................. Insert semi-rigid
prosthesis.
----------------------------------------------------------------------------------------------------------------
[[Page 66848]]
53445................. Insert uro/ves nck 0386 Level II Prosthetic 63.53 31.77
sphincter. Urological Procedures.
53447................. Remove/replace ur
sphincter.
54401................. Insert self-contd
prosthesis.
54405................. Insert multi-comp penis
pros.
54410................. Remove/replace penis
prosth.
54416................. Remv/repl penis contain
pros.
----------------------------------------------------------------------------------------------------------------
33224................. Insert pacing lead & 0418 Insertion of Left 82.52 41.26
connect. Ventricular Pacing
Elect.
33225................. L ventric pacing lead
add-on.
----------------------------------------------------------------------------------------------------------------
36566................. Insert tunneled cv cath. 0625 Level IV Vascular 58.88 29.44
Access Procedures.
----------------------------------------------------------------------------------------------------------------
33213................. Insertion of pulse 0654 Insertion/Replacement 77.13 38.57
generator. of a permanent dual
chamber pacemaker.
----------------------------------------------------------------------------------------------------------------
33214................. Upgrade of pacemaker 0655 Insertion/Replacement/ 74.62 37.31
system. Conversion of a
permanent dual chamber
pacemaker.
33208................. Insertion of heart
pacemaker.
----------------------------------------------------------------------------------------------------------------
33282................. Implant pat-active ht 0680 Insertion of Patient 73.15 36.58
record. Activated Event
Recorders.
----------------------------------------------------------------------------------------------------------------
Table 59.--Devices for Which the ``FB'' or ``FC'' Modifier Must Be
Reported With the Procedure Code When Furnished Without Cost or for
Which Full or Partial Credit is Received
------------------------------------------------------------------------
Device HCPCS code Short descriptor
------------------------------------------------------------------------
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, neurostimulators.
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.
C1881..................................... Dialysis access system.
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.
------------------------------------------------------------------------
2. Payment for Covered Ancillary Services
Our final CY 2008 payment policies under the revised ASC payment
system for covered ancillary services vary according to the particular
type of service and its payment policy under the OPPS. Our overall
policy provides for separate ASC payment for certain ancillary services
integrally related to the provision of ASC covered surgical procedures
if those services are paid separately under the OPPS. Thus, we
established a policy to align ASC payment bundles with those under the
OPPS. Specifically, our final ASC payment policies provide separate ASC
payment for brachytherapy sources and drugs and biologicals that are
separately paid under the OPPS at the OPPS rates, while we pay for
radiology services at the lower of the MPFS nonfacility PE RVU (or
technical component) amount or the rate calculated according to the
standard methodology of the revised ASC payment system based on the
OPPS relative payment weight for the service.
As evidenced by our final policies for the CY 2008 revised ASC
payment system, our intention is to maintain consistent payment and
packaging policies across HOPD and ASC settings for covered ancillary
services that are integral to covered surgical procedures performed in
ASCs. Therefore, consistent with our policy to pay separately only for
those ancillary services that are paid separately under the OPPS, in
the CY 2008 OPPS/ASC proposed rule (72 FR 42790), we also proposed to
package into the ASC payment for covered surgical procedures the costs
of those ancillary services that are proposed to be packaged under the
OPPS for CY 2008. Certain covered ancillary services that we proposed
to package for the CY 2008 OPPS were assigned payment indicator ``Z2''
or ``Z3'' in the August 2, 2007 revised ASC payment system final rule,
but they were assigned payment indicator ``N1'' in Addendum BB to the
CY 2008 OPPS/ASC proposed rule. We refer readers to section II.A.4.c.
of this final rule with comment period for a description of the CY 2008
OPPS proposed packaging approach that we also proposed to adopt in
ASCs. In addition, OPPS payments for brachytherapy sources and
separately payable drugs and biologicals are discussed in sections
VII.B. and V. of this final rule with comment period, respectively.
Other separately paid covered ancillary services in ASCs, specifically
corneal tissue acquisition and devices with OPPS pass-through status,
do not have prospectively established ASC payment rates according to
the final policies of the revised ASC payment system. Payments for
devices with pass through status under the OPPS, for which separate
payment would be made to ASCs at contractor-priced rates, are discussed
in detail in section VI. of this final rule with comment period.
We received many public comments on our proposal for payment of
covered ancillary services under the CY 2008 revised ASC payment
system. A
[[Page 66849]]
summary of the public comments and our response follow.
Comment: Many commenters disagree with the proposal to package
payment for CPT codes 72285 (Discography, cervical or thoracic,
radiologic supervision and interpretation) and 72295 (Discography,
lumbar, radiological supervision and interpretation), in accordance
with the proposed packaging policy under the OPPS. The commenters were
concerned that the surgical procedures that are packaged into CPT codes
72285 and 72295 (CPT codes 62290 (Injection procedure for discography,
each level; lumbar) and 62291 (Injection procedure for discography,
each level; cervical or thoracic)), as well as a number of other
surgical procedures that are packaged into other codes in the range of
CPT codes for radiology services, will no longer be available in ASCs
as a result of the new packaging policy. The commenters requested that
CMS develop a payment policy like that applied to these codes under the
OPPS to allow separate payment for the services when they are provided
without a covered surgical procedure.
Response: As explained in the August 2, 2007 revised ASC payment
system final rule (72 FR 42485), we continue to believe that packaging
payment for those surgical procedures that are packaged under the OPPS
is appropriate under the revised ASC payment system. Our policy is
aligned with the recommendation of the Practicing Physicians Advisory
Council (PPAC) to apply payment policies uniformly in the ASC and HOPD
settings. It also maintains comparable payment bundles under the OPPS
and the revised ASC payment system for the services, consistent with
the recommendation of MedPAC to maintain consistent payment bundles
under both payment systems.
Under the OPPS, the services described by CPT codes 72285 and 72295
may be provided without another separately paid surgical procedure and,
therefore, have been assigned to the OPPS status indicator ``Q'' to
indicate that payment for the service is usually packaged into payment
for another procedure but that under some circumstances, the service
may be paid separately. For example, in the HOPD, if the service
described by CPT code 72285 is provided without another separately paid
service (into which it usually would be packaged), then a separate
payment is made for it under the OPPS.
According to the revised ASC payment system policies, there is no
instance in which payment for a service is packaged only sometimes. The
services that are packaged into covered surgical procedures are always
packaged; that is, they are unconditionally packaged. There is no
payment policy for ASCs that parallels the OPPS policy for the ``Q''
status indicator which, under OPPS conditional packaging policies,
provides packaged payment for the service unless it is billed without
any other separately payable OPPS service (or in some cases, without
any other separately payable surgical procedure) on the same day, in
which case separate OPPS payment is allowed for the status indicator
``Q'' service. In ASCs, there is no circumstance in which Medicare
would make separate payment to an ASC for a service if it was not
performed with a covered surgical procedure. Only covered surgical
procedures may be paid when billed alone, without other separately
payable services. Our policy is to make separate payment for all
covered surgical procedures and for all covered ancillary services
which, by definition, are provided integral to a covered surgical
procedure performed in an ASC. Therefore, under the revised ASC payment
system, the radiology services of concern to the commenters are
packaged for CY 2008.
After consideration of the public comments received, we are
providing CY 2008 payment for covered ancillary procedures in
accordance with their final payment policies under the revised ASC
payment system as described in the August 2, 2007 revised ASC payment
system final rule and their final treatment under the CY 2008 OPPS.
Covered ancillary services and their final payment indicators are
listed in Addendum BB to this final rule with comment period.
G. Physician Payment for Procedures and Services Provided in ASCs
Under current policy, when physicians perform surgical procedures
in ASCs that are included on the ASC list of covered surgical
procedures, they are paid under the MPFS for the PE component using the
facility PE RVUs. This is appropriate because the surgical procedures
are those for which Medicare allows facility payment to ASCs. However,
when physicians perform surgical procedures in ASCs that are not
included on the ASC list of covered surgical procedures and for which
Medicare does not allow facility payments to ASCs, physicians are paid
for the PE component at the higher MPFS nonfacility PE RVUs (unless a
nonfacility rate does not exist, in which case Medicare pays the
physician at the facility rate). These policies are set forth in
Sec. Sec. 414.22(b)(5)(i)(A) and (b)(5)(i)(B), respectively.
Furthermore, physician payment for nonsurgical services provided in
ASCs, for which no facility payment is made to ASCs under the existing
ASC payment system, varies based on local Medicare contractor policy.
Some contractors pay physicians only for the professional component
(PC) of the service and others make payment to the physician for the
technical component (TC) as well. Under the current policy, as
described in the CY 2002 Physician Fee Schedule final rule with comment
period (66 FR 55264), Medicare payment to the physician for a
noncovered surgical procedure performed in an ASC constitutes payment
in full. This is so even if the physician is paid the facility rate
(because there is no nonfacility rate). In this case, there is no
beneficiary liability other than the deductible and copayment for the
physician's services.
According to the policy adopted in the August 2, 2007 revised ASC
payment system final rule, Medicare will make facility payments to ASCs
for all covered surgical procedures except those that could pose a
significant risk to beneficiary safety or would be expected to require
active medical monitoring and care at midnight following the procedure
(that is, an overnight stay). The revised policy will result in a
significant expansion in the number and type of surgical procedures for
which Medicare will make an ASC facility payment. The final payment
policy for the revised ASC payment system also allows separate payments
to ASCs for certain covered ancillary services (for example, some
drugs, brachytherapy sources, and certain radiology services) that are
provided integral to an ASC covered surgical procedure. According to
the final policy, when covered ancillary services, which are integral
to the performance of a covered surgical procedure and are performed on
the same day as the covered surgery, immediately before, during or
following the procedure, Medicare will allow separate ASC payment for
those services.
The revised ASC payment system is based on the APC groups and
payment weights of the OPPS. We believe ASCs are facilities that are
similar, insofar as the delivery of surgical and related nonsurgical
services, to HOPDs. Specifically, when services are provided in ASCs,
the ASC, not the physician, bears responsibility for the facility costs
associated with the service. This situation parallels the hospital
facility resource responsibility for hospital outpatient services.
Therefore, as explained in the CY 2008 OPPS/ASC
[[Page 66850]]
proposed rule, we believe it would be more appropriate for physicians
to be paid for all services furnished in ASCs just as they would be
paid for all services furnished in the hospital outpatient setting. In
addition, because we have adopted a final policy for the revised ASC
payment system that identifies and excludes from ASC payment only those
procedures that could pose a significant risk to beneficiary safety or
would be expected to require an overnight stay, we believe that it
would be incongruous with the revised ASC payment system methodology to
continue to pay the higher nonfacility rate to physicians who furnish
excluded ASC procedures. Because these excluded procedures have been
specifically identified by CMS as procedures that could pose a
significant risk to beneficiary safety or would be expected to require
an overnight stay, we do not believe it would be appropriate to provide
payment based on the higher nonfacility PE RVUs to physicians who
furnish them. In fact, we do not expect that the excluded procedures
will be performed in ASCs after the revised ASC payment system is
implemented on January 1, 2008. Therefore, we proposed to revise
Sec. Sec. 414.22(b)(5)(i)(A) and (b)(5)(i)(B) to reflect this proposed
policy.
We believe that the proposed revised policy would provide
appropriate payment to physicians for services provided in the ASC
facility setting and would encourage the most appropriate utilization
of ASCs. For procedures that are not excluded from coverage under the
revised ASC payment system, the ASC would be paid for the covered
surgical procedure and associated covered ancillary services, and the
physician would be paid for the professional work and facility PE
associated with performing the procedure. In the case of noncovered
surgical procedures or other noncovered services provided in ASCs,
Medicare would make no payment to the ASC under the revised ASC payment
system and no payment to the physician under the MPFS for the facility
resources associated with providing those services. Although the
current MPFS payment policy provides payment to the physician for some
facility costs as if the service were being furnished in a physician's
office, according to the final policy of the revised payment system,
the services would not be covered ASC services. Consistent with
Medicare payment policy in other care settings, no payment for facility
costs would be made for the noncovered services. In this case, the
noncovered services have been excluded from ASC payment for safety
reasons, because they are expected to require an overnight stay, or
because they are not surgical procedures, and they would not be covered
by Medicare either directly, under the ASC payment system, or
indirectly, through PE payments to the physicians who perform them.
In summary, under the proposed policy, physicians would receive
payment for all surgical and nonsurgical services furnished in ASCs
based on the facility PE RVUs and excluding the TC payment, if
applicable, consistent with physician payment for HOPD services.
Medicare would make no payment for facility services to ASCs or
physicians for procedures or services that are performed in ASCs but
that are excluded from the list of covered ASC surgical procedures or
that are not covered ancillary services. While physicians would be paid
for these services based on the facility PE RVUs, physicians would no
longer receive the additional payment for the associated facility
resources.
Consistent with the current OPPS payment policy that prohibits
facility payments to the hospital for noncovered services (such as
those surgical procedures on the OPPS inpatient list) and makes the
beneficiary liable for those charges, this proposed policy would make
beneficiaries responsible for the ASC charges for noncovered services
furnished to them in ASCs.
We received a number of public comments on our proposal to pay
physicians at the facility PE rate instead of the nonfacility PE amount
for excluded procedures, to not pay physicians the technical component
(TC) payment for ancillary services, and to make beneficiaries
responsible for the ASC charges for noncovered services furnished to
them in ASCs. A summary of the public comments and our responses
follow.
Comment: Several commenters requested that CMS not proceed with the
proposal and continue the existing payment policy for excluded services
performed in ASCs and payment for the TC associated with ancillary
services to physicians who provide those services. One commenter stated
that he provides permanent seed prostate brachytherapy services to
Medicare beneficiaries in hospital and ASC settings. Under current
Medicare payment policy, the commenter received the TC payment for a
number of services in the radiology range of CPT codes because he
brought the necessary equipment to the facility with him when he came
to provide the brachytherapy procedures. The commenter stated that he
would be able to provide prostate brachytherapy services to a larger
number of Medicare patients if he could continue to receive the TC
payment for the ancillary services.
Response: Our proposed policy for physician payment would preclude
physicians from receiving the TC payment for procedures performed in
ASCs because, under the revised ASC payment system, Medicare will make
payment only to ASCs for ancillary services provided integral to
covered surgical procedures. The costs associated with the provision of
covered ancillary services are facility resources, and Medicare will
provide separate ASC payment for those costs. However, the ASC is not
precluded from contracting with another entity to provide the equipment
and supplies required to provide specific services. The ASC would make
payment to its contractors.
Comment: Some commenters stated that beneficiaries should not be
liable for the costs of procedures and services that are not covered
when performed in ASCs. A few commenters believed that the beneficiary
should only be liable for his or her deductible and coinsurance
amounts, just as he or she would be for covered procedures in ASCs. One
commenter stated that the course of a planned, covered procedure cannot
always be determined in advance because the physician may have to alter
the procedure intraoperatively, and sometimes that alteration results
in performance of an excluded, noncovered procedure. The commenter did
not believe it would be fair to hold the beneficiary liable in such
cases. One commenter suggested that CMS create a modifier that the ASC
would use to identify cases in which the planned, covered procedure was
altered intraoperatively due to unexpected circumstances. The commenter
indicated that payment in those cases could be priced by the contractor
based on review of the operative report. The commenter stated that use
of the modifier would enable CMS to track such occurrences and could
audit as needed.
Response: We appreciate the commenters'' concern regarding
beneficiary liability for excluded ASC procedures. However, because we
have adopted a final policy for the revised ASC payment system that
identifies and excludes from ASC payment only those procedures that
pose a significant risk to beneficiary safety or would be expected to
require an overnight stay, we continue to believe that it would be
incongruous with the revised ASC payment system methodology to continue
to pay the higher nonfacility
[[Page 66851]]
rate to physicians who furnish excluded ASC procedures. Therefore,
consistent with Medicare payment policy in other care settings, no
payment for facility costs would be made for the noncovered services,
and the beneficiary would be liable. As we explained in the CY 2008
OPPS/ASC proposed rule, because of the significant expansion of the ASC
list of covered surgical procedures, we expect that excluded procedures
will not be performed in ASCs beginning in CY 2008.
After consideration of the public comments received, we are
finalizing our CY 2008 proposal, without modification, to pay
physicians only the facility PE amount and exclude payment of the TC if
applicable, for the performance of surgical procedures and nonsurgical
services in ASCs and to make beneficiaries liable for the facility
charges for procedures provided in the ASC that are excluded from ASC
payment.
H. Changes to Definitions of ``Radiology and Certain Other Imaging
Services'' and ``Outpatient Prescription Drugs''
In section 1877(h)(6) of the Act, the Congress defined the
``designated health services'' (DHS) that are subject to the physician
self-referral prohibition to include 11 broad categories of services.
In our regulations at Sec. 411.351, we define each of the 11 DHS
categories, including ``radiology and certain other imaging services''
and ``outpatient prescription drugs.'' The definition of ``designated
health services'' at Sec. 411.351 excludes ``services that are
reimbursed by Medicare as part of a composite rate (for example, ASC
services or SNF Part A services),'' except to the extent that the DHS
categories are themselves payable through a composite rate. In the
definition of ``radiology and certain other imaging services'' at Sec.
411.351, we previously excluded x-ray, fluoroscopy, and ultrasound
procedures that require the insertion of a needle, catheter, tube, or
probe through the skin or into a body orifice. In addition, the
definition of ``radiology and certain other imaging services'' excludes
radiology procedures that are integral to the performance of a
nonradiological medical procedure and (1) performed during the
nonradiological medical procedure or (2) performed immediately
following the nonradiological medical procedure when necessary to
confirm placement of an item placed during the nonradiological medical
procedure. Radiology and certain other imaging services performed
before a nonradiological medical procedure have been subject to the
physician self-referral prohibition.
Taken together, these provisions effectively excluded from the
physician self-referral prohibition referrals for: (1) Radiology and
certain other imaging services that were paid through the ASC composite
payment rate; and (2) radiology procedures that were integral to the
performance of an ASC covered surgical procedure, that were paid
separately, and that were performed in the ASC either (a) during the
surgical procedure or (b) immediately after the surgical procedure if
required to confirm placement of an item placed during the
nonradiological medical procedure. (For physician self-referral
purposes, we have considered radiology and certain other imaging
services that are performed while the patient is still in the operating
room to confirm that ASC surgery is effective to be performed during
the surgical procedure.)
Under the August 2, 2007 revised ASC payment system final rule (72
FR 42470), effective January 1, 2008, Medicare makes a bundled or
composite payment for facility services and a separate payment for each
covered ancillary service that is integral to a covered surgical
procedure and performed in the ASC on the same day. Because facility
services continue to be paid under a composite rate, a physician
referral for any radiology or other imaging service or outpatient
prescription drug that is paid for as a facility service under Sec.
416.164(a) is excluded from the physician self-referral prohibition
under paragraph (2) of the definition of ``designated health services''
at Sec. 411.351.
Covered ancillary services for which separate payment is made per
item or service include many radiology and certain other imaging
services. The August 2, 2007 revised ASC payment system final rule
discusses the radiology services that are included in new Sec.
416.164(b) as covered ancillary services integral to, and furnished on
the same day as the ASC surgical procedure (72 FR 42496 through 42498).
Under the revised ASC payment system, a greater variety of surgical
procedures than previously allowed can be provided as ASC services,
and, thus, a greater number of ``radiology and certain other imaging
services'' would be subject to the physician self-referral prohibition.
Accordingly, in the August 2, 2007 rule proposing changes to both the
outpatient hospital prospective payment system and the ASC payment
system, we proposed to revise the physician self-referral definition of
``radiology and certain other imaging services'' to exclude those
radiology and imaging services that are ``covered ancillary services,''
as defined at 416.164(b), for which separate payment is made under the
revised ASC payment system (72 FR 42792). That is, we proposed that
those radiology and imaging procedures that are integral to a covered
ASC surgical procedure and that are performed immediately before,
during, or immediately following the surgical procedure (that is, on
the same day) would not constitute ``radiology and certain other
imaging procedures'' for purposes of the physician self-referral law.
We noted that if we did not revise the definition of ``radiology and
certain other imaging services'' for physician self-referral purposes
to exclude these radiology and other imaging procedures, the physician
self-referral law would prohibit an ASC from billing Medicare for these
separately payable, integral ancillary services rendered to patients
who had been referred by a physician with an ownership or investment
interest in, or compensation relationship with, an ASC unless an
exception applies.
For the reasons that warrant our revising the definition of
``radiology and certain other imaging services,'' we also proposed to
exclude from the definition of ``outpatient prescription drugs'' at
Sec. 411.351, drugs that are ``covered as ancillary services'' as
defined at new Sec. 416.164(b) under the revised ASC payment system.
These drugs are furnished, for example, during the immediate
postoperative recovery period to a patient to reduce suffering from
nausea or pain. Under our proposal, such drugs would not constitute
DHS, although the physician self-referral provisions would continue to
be applicable when an ASC furnishes outpatient prescription drugs for
use in the patient's home.
Although we believe that physician referrals to entities with which
they have a financial relationship are susceptible to abuse, we believe
that our revision to the definitions of ``radiology and certain other
imaging services'' and ``outpatient prescription drugs'' promote
quality of care without posing a risk of abuse. The change will promote
quality of care by allowing patients timely, convenient access to
outpatient drugs and radiology and imaging services that are integral
to an ASC procedure and necessary for its safe performance in an ASC.
The risk of program abuse is avoided by the requirement that the items
and services must be ``integral to'' the ASC procedure (that is,
performed in the ASC immediately preceding, during, or immediately
following the covered surgical procedure). We caution that only those
items and services that
[[Page 66852]]
are integral to an ASC procedure and performed on the same day as the
covered surgical procedure will qualify for the exclusion from the
definitions of ``radiology and certain other imaging services'' and
``outpatient prescription drugs.'' Other separately billable services
that do not satisfy these conditions will remain subject to the
physician self-referral prohibition. We will continue to monitor the
provision of services in ASCs for potential abuse.
In addition, for clarity, we proposed to make a technical
correction to paragraph (2) of the definition of ``radiology and
certain other imaging services'' at Sec. 411.351 to exclude from the
definition not only ``radiology procedures'' that are integral to the
performance of a ``nonradiological procedure,'' but also to exclude
``radiology and certain other imaging services'' that are integral to
the performance of ``a medical procedure that is not identified on the
List of CPT/HCPCS Codes as a `radiology or certain other imaging
service.' ''
We received one public comment supporting the proposed change in
the definition of ``radiology and other imaging services.'' Two
additional public comments concern radioactive seeds and ribbons
(radioactive sources) implanted during brachytherapy procedures
performed in an ASC. These items are included within the DHS category
of ``radiation therapy and supplies.''
Comment: Two commenters asked CMS to exclude from the definition of
DHS radioactive sources (including seeds and ribbons) furnished during
a brachytherapy procedure performed in an ASC because DHS, as defined
at Sec. 411.351, does not include ``services that are reimbursed by
Medicare as part of a composite rate (for example, ambulatory surgical
center services * * *).'' In addition, the commenter suggested that,
consistent with our proposal to exclude radiology services and
outpatient prescription drugs that are ``covered ancillary services''
furnished on the same day as an ASC procedure, we should exclude from
the definition of ``radiation therapy services and supplies''
brachytherapy sources that are also ASC covered ancillary services
integral to a covered surgical procedure for which separate payment is
made under new Sec. 416.164(b). The commenters pointed out that, if
these radioactive sources were not excluded from the physician self-
referral prohibition, many urologist-owners of ASCs would not be able
to order and furnish brachytherapy services because the ASC must bill
Medicare for the radioactive sources and they are not included in a
composite rate.
Response: The DHS category ``radiation therapy services and
supplies'' includes radioactive sources used in connection with
brachytherapy procedures. The commenters are correct that a urologist
or other type of physician who has an ownership or investment interest
in, or a compensation relationship with, an ASC may not refer a
Medicare patient to the ASC for a brachytherapy procedure, unless an
exception is satisfied.
Previously, except for brachytherapy procedures performed as
inpatient or outpatient hospital procedures, Medicare made payment for
the radioactive sources to the individual or entity that furnished the
radioactive sources. Under the ASC payment system effective for
procedures performed on or after January 1, 2008, Medicare pays the ASC
for facility services that are packaged into the ASC payment. In
addition, Medicare makes a separate payment to an ASC for certain
ancillary items and services, including brachytherapy sources.
The commenters are correct that, without an exception under the
physician self-referral provisions, a urologist who refers a Medicare
patient for an ASC-covered brachytherapy procedure may not have either
an ownership or investment interest in the ASC or a compensation
relationship with the ASC because the brachytherapy sources are DHS.
Although we did not propose to exclude, nor are we excluding in
this final rule with comment period, brachytherapy sources supplied in
connection with an ASC-covered brachytherapy procedure, we intend to
consider this issue, and if we decide to propose an exception, we will
include such changes in a proposed rule and seek public comment.
We are adopting the proposed physician self-referral provisions
without change and we are making one additional technical,
nonsubstantive change. We are revising the definition of ``designated
health services'' at Sec. 411.351 to reflect the fact that CMS no
longer pays for all ASC procedures under a composite rate.
Specifically, the definition will refer to ``SNF Part A payments or ASC
services identified at Sec. 416.164(a)'' as examples of services that
Medicare pays as part of a composite rate. Section 416.164(a) sets
forth the facility services for which a bundled or composite payment is
made under the revised ASC payment system.
I. New Technology Intraocular Lenses
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, Pub.
L. 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), Pub. L. 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), Pub. L. 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), Pub. L. 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.
[[Page 66853]]
Since June 16, 1999, we have issued a series of Federal Register
notices to list lenses for which we received requests for an 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 specifically to NTIOLs on April 28, 2006 (71 FR 25176).
2. Changes to the NTIOL Determination Process Finalized for CY 2008
In the CY 2007 OPPS/ASC final rule with comment period, we
finalized our proposal to update and streamline the process for
recognizing IOLs inserted during or subsequent to cataract extraction
as belonging to a new, active NTIOL class that is qualified for a
payment adjustment. The following is a summary of the changes beginning
for CY 2008 that were finalized in the CY 2007 OPPS/ASC final rule with
comment period (71 FR 68176 through 68181).
We modified the historical 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's determinations concerning lenses
assigned to classes of NTIOLs for which an ASC payment adjustment would
be made. In the CY 2007 OPPS/ASC final rule with comment period (71 FR
68176), we specified that these NTIOL-related notifications will be
fully integrated into the annual notice and comment rulemaking cycle
for updating the ASC payment rates, the specific payment system in
which NTIOL payment adjustments are made. Our final policy for updating
the revised ASC payment system to be implemented in January 2008 will
utilize an annual update process in coordination with notice and
comment rulemaking for 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 established 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.
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 was identified for each class. In the CY 2007
final rule, we finalized our proposal 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.
For a request to be considered complete, we require submission of
the information that is found in the guidance document entitled
``Application Process and Information Requirements for Requests for a
New Class of New Technology Intraocular Lens (NTIOL)'' posted on the
CMS Web site at: http://www.cms.hhs.gov/ASCPayment/05--NTIOLs.asp.
As stated in the CY 2007 OPPS/ASC final rule with comment period
(71 FR 68180), there are three possible outcomes from our 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 HCPCS 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 discussed our plan to summarize briefly in the final rule
the evidence that was reviewed, the public comments, and the basis for
our determinations. We established that when a new NTIOL class is
created, we would 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.
3. NTIOL Application Process for CY 2008 Payment Adjustment
To provide process and information requirements for applications
requesting a review of the appropriateness of the payment amount for
insertion of an IOL to ensure that the ASC payment for covered surgical
procedures includes
[[Page 66854]]
payment that is reasonable and related to the cost of acquiring a lens
that is approved as belonging to a new class of NTIOLs, in February
2007 we posted the guidance document to the CMS Web site regarding such
requests as described above. We did not receive any review requests by
the deadline of April 1, 2007, in response to the announcement made in
the CY 2007 OPPS/ASC final rule with comment period (71 FR 68181)
soliciting CY 2008 requests for review of the appropriateness of the
payment amount for new classes of NTIOLs furnished in ASCs.
We note that we have also 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.
This guidance document provides specific details regarding requests
for recognition of IOLs as belonging to an existing, active NTIOL
class, the review process, and information required for a request to
review. Currently, there is one active NTIOL class 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 class of NTIOLs. That is,
review of candidate lenses for membership in an existing, active NTIOL
class is ongoing and not limited to the annual review process that
applies to the establishment of new NTIOL classes. We ordinarily
complete the review of such a request within 90 days of receipt, and
upon completion of our review, we 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 in an ASC.
4. 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 the
following table:
----------------------------------------------------------------------------------------------------------------
$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.
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,
Z9002, ZA9003 and
AR40xEM; Alcon
Acrysof[supreg] IQ
Model SN60WF and
Acrysert Delivery
System Model SN60WS;
Bausch & Lomb
Sofport AO model
LI61AOV.
----------------------------------------------------------------------------------------------------------------
5. 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/
ASC final rule with comment period, we revised Sec. 416.200(a) through
(c) to clarify how the IOL payment adjustment will be made and how an
NTIOL will be paid after expiration of the payment adjustment, as well
as made minor editorial changes to Sec. 416.200(d). For CY 2008, we
did not propose to revise, nor are we revising in this final rule with
comment period, the current payment adjustment amount, but we reiterate
our intention, as stated in the CY 2007 final rule, to reevaluate
whether or not the ASC payment rates established for cataract surgery
with IOL insertion are appropriate when a lens determined to be an
NTIOL is furnished after we have implemented the revised ASC payment
system in CY 2008.
6. CY 2008 ASC Payment for Insertion of IOLs
In accordance with the final policies of the revised ASC payment
system for CY 2008, payment for IOL insertion services will be
established according to the standard payment methodology of the
revised payment system, which applies the ASC budget neutrality
adjustment to the OPPS conversion factor to calculate an ASC conversion
factor that is then multiplied by the ASC payment weight for the
surgical procedure to implant the IOL. CY 2008 ASC payment for the cost
of a conventional lens will be packaged into the payment for the
associated covered surgical procedure performed by the ASC. We included
the proposed CY 2008 ASC payment rates for IOL insertion procedures in
Table 66 of the proposed rule (72 FR 42795) that is reprinted, with
final CY 2008 ASC payment rates, below.
Comment: Several commenters supported the revision to the process
for recognizing IOLs inserted during or subsequent to cataract
extraction as belonging to a new or active NTIOL class. One commenter
suggested that, for purposes of administrative simplicity, CMS should
make the comment period on requests for new NTIOL classes 60 days,
rather than 30 days as proposed. The commenter believed that Congress
intended that CMS provide at least a 30-day comment period and argued
that further adjusting the comment period for NTIOLs to 60 days would
be consistent with the comment period for the rest of the OPPS/ASC
proposed rule.
Response: We appreciate the commenters' continuing support
regarding our recent revision to the process for recognizing IOLs
inserted during or subsequent to cataract extraction as belonging to a
new or active NTIOL class. We continue to believe that aligning the
NTIOL process with annual updates to the OPPS and the revised ASC
payment system promotes coordination and efficiency, thereby
streamlining and expediting the NTIOL notification, comment, and review
process. In response to the comment urging us to adjust the comment
period regarding requests to establish new classes of NTIOLs to 60
days, we note that section 141(b)(3) of the Social Security Act
Amendments of 1994 (SSAA 1994), Pub. L. 103-432, clearly requires us to
provide a 30-day comment period on lenses that are the subject of
requests for recognition as belonging to a new class of NTIOLs.
Therefore, we will continue to provide a 30-day comment period on
lenses that are the subject of requests for recognition as members of a
new class of NTIOLs.
After considering the public comments received, we are finalizing,
[[Page 66855]]
without modification, the process and timelines proposed for NTIOL
consideration under the ASC payment system. The payment adjustment for
NTIOLs will continue to be $50 for CY 2008.
7. Announcement of CY 2008 Deadline for Submitting Requests for CMS
Review of Appropriateness of ASC Payment for Insertion of an NTIOL
Following Cataract Surgery
In accordance with Sec. 416.185(a) of our regulations, as revised
by the CY 2007 OPPS/ASC final rule with comment period, CMS announces
that, in order to be considered for payment effective January 1, 2009,
requests for a review of an application for a new class of new
technology IOLs must be received at CMS by 5 p.m., EST, on March 14,
2008. 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.
Table 60.--Insertion of IOL Procedures and Their CY 2008 ASC Payment
Rates
------------------------------------------------------------------------
CY 2008 ASC
HCPCS code Long descriptor payment
------------------------------------------------------------------------
66983...................... Intracapsular cataract $976.76
extraction with insertion of
intraocular lens prosthesis
(one stage procedure).
66984...................... Extracapsular cataract removal 976.76
with insertion of intraocular
lens prosthesis (one stage
procedure), manual or
mechanical technique (e.g.,
irrigation and aspiration or
phacoemulsification).
66985...................... Insertion of intraocular lens 866.51
prosthesis (secondary
implant), not associated with
concurrent cataract removal.
66986...................... Exchange of intraocular lens.. 866.51
------------------------------------------------------------------------
J. ASC Payment and Comment Indicators
In addition to the payment indicators that we introduced in the
August 2, 2007 revised ASC payment system final rule, we also
introduced comment indicators for the ASC payment system in the CY 2008
OPPS/ASC proposed rule (72 FR 42795). We created Addendum DD1 to define
ASC payment indicators that we will use in Addenda AA and BB to provide
payment information regarding covered surgical procedures and covered
ancillary services, respectively, under the revised ASC payment system.
Analogous to the OPPS payment status indicators that we define in
Addendum D1 to the annual OPPS proposed and final rules, the ASC
payment indicators in Addendum DD1 are intended to capture policy-
relevant characteristics of HCPCS codes that may receive packaged or
separate payment in ASCs, including: their ASC payment status prior to
CY 2008; their designations as device-intensive; their designations as
office-based and the corresponding ASC payment methodology; and their
classifications as separately payable radiology services, brachytherapy
sources, OPPS pass-through devices, corneal tissue acquisition
services, drugs or biologicals, or NTIOLs.
We have also created new Addendum DD2 that lists the ASC comment
indicators. Like the comment indicators used in the OPPS, the ASC
comment indicators used in Addenda AA and BB to this OPPS/ASC final
rule with comment period serve to identify, for the revised ASC payment
system, the status of a specific HCPCS code and its payment indicator
with respect to the timeframe when comments would be accepted. The
comment indicator ``NI'' is used in this final rule with comment period
to indicate new HCPCS codes for which the interim payment indicator
assigned is subject to comment in this final rule.
The changes for CY 2008 that we proposed to the payment indicators
assigned to HCPCS codes for procedures and services in the August 2,
2007 revised ASC payment system final rule were identified with a
``CH'' in the OPPS/ASC proposed rule and were subject to comment during
the 60-day comment period provided for that proposed rule. ``CH'' is
used in Addenda AA and BB to this CY 2008 OPPS/ASC final rule with
comment period to indicate that a new payment indicator (in comparison
with that in the August 2, 2007 revised ASC payment system final rule)
has been assigned to an active HCPCS code for the next calendar year;
that an active HCPCS code has been added to the list of procedures or
services payable in ASCs; or that an active HCPCS code will be deleted
at the end of the current calendar year. The ``CH'' comment indicators
that are published in this CY 2008 OPPS/ASC final rule with comment
period are provided to alert our readers that a change has been made
since the August 2, 2007 revised ASC payment system final rule, but do
not indicate that the change is subject to comment. The full
definitions for the comment indicators are provided in Addendum DD2 to
this final rule with comment period.
We did not receive any comments that addressed our proposal related
to implementation and use of comment indicators for the revised ASC
payment system. Therefore, we are finalizing our proposal, without
modification, to adopt the comment indicators as defined in Addendum
DD2 to this final rule with comment period.
K. ASC Policy and Payment Recommendations
The GAO published the statutorily mandated report entitled,
``Medicare: Payment for Ambulatory Surgical Centers Should Be Based on
the Hospital Outpatient Payment System'' (GAO-07-86) on November 30,
2006. We considered the report's methodology, findings, and
recommendations in the development of the August 2, 2007 revised ASC
payment system final rule. The GAO methodology, results, and
recommendations are summarized below.
The GAO was directed to conduct a study comparing the relative
costs of procedures furnished in ASCs to those furnished in HOPDs paid
under the OPPS, including examining the accuracy of the APC with
respect to surgical procedures furnished in ASCs. Section 626(d) of
Pub. L. 108-173 indicated that the report should include
recommendations on the following matters:
1. Appropriateness of using groups of covered services and relative
weights established for the OPPS as the basis of payment for ASCs.
2. If the OPPS relative weights are appropriate for this purpose,
whether
[[Page 66856]]
the ASC payments should be based on a uniform percentage of the payment
rates or weights under the OPPS, or should vary, or the weights should
be revised based on specific procedures or types of services.
3. Whether a geographic adjustment should be used for ASC payment
and, if so, the labor and nonlabor shares of such payment.
Based on its extensive analyses, the GAO determined that the APC
groups in the OPPS accurately reflect the relative costs of the
procedures performed in ASCs. The GAO's analysis of the cost ratios
showed that the ASC-to-APC cost ratios were more tightly distributed
around their median cost ratio than were the OPPS-to-APC cost ratios.
The ASC-to-APC median cost ratio is a comparison of the median cost of
each of the 20 surgical procedures with the highest ASC claims volume
to the median cost of the APC group in which it would be placed under
the OPPS, while the OPPS-to-APC cost ratio is a comparison of the
median cost of each of those same procedures under the OPPS with the
median cost of its assigned APC group. These patterns demonstrated that
the APC groups reflect the relative costs of procedures performed by
ASCs as they do for procedures performed in HOPDs and, therefore, that
the APC groups could be used as the basis for an ASC payment system.
The GAO determined, in fact, that there was less variation in the ASC
setting between individual procedures' costs and the costs of their
assigned APC groups than there is in the HOPD setting. It concluded
that, as a group, the costs of procedures performed in ASCs have a
relatively consistent relationship with the costs of the APC groups to
which they are assigned under the OPPS. The GAO's analysis also found
that procedures in the ASC setting had substantially lower costs than
those same procedures in the HOPD. While ASC costs for individual
procedures varied, in general, the median costs for procedures were
lower in ASCs, relative to the median costs of their APC groups, than
the median costs for the same procedures in HOPDs. The median cost
ratio among all ASC procedures was 0.39 (0.84 when weighted by Medicare
volume based on CY 2004 claims), whereas the median cost ratio among
all OPPS procedures was 1.04.
The GAO found many similarities in the additional items and
services provided by ASCs and HOPDs for the top 20 ASC procedures.
However, of these additional items and services, few resulted in
additional payment in one setting but not the other. HOPDs were paid
for some of the related services separately, while in the ASC setting,
other Part B suppliers billed Medicare and received payment for many of
the related services.
Finally, in its analysis of labor-related costs, the GAO determined
that the mean labor-related proportion of costs was 50 percent. The
range of the labor-related costs for the middle 50 percent of
responding ASCs was 43 percent to 57 percent of total costs.
Based on its findings from the study, the GAO recommended that CMS
implement a payment system for procedures performed in ASCs based on
the OPPS, taking into account the lower relative costs of procedures
performed in ASCs compared to HOPDs in determining ASC payment rates.
Comment: One commenter expressed concern that the public was denied
time to analyze and respond to the findings in the congressionally
mandated GAO report on ASC costs. The commenter believed that CMS'
reliance on the GAO Report findings in finalizing the development of
the revised payment system for ASCs, without also considering comments
from the public about those findings, potentially violated principles
of fairness and transparency. The commenter specifically stated that
the report's findings are flawed and that the OPPS is not a relative
cost proxy for ASCs' costs for gastrointestinal (GI) procedures.
Response: As we discussed in our response to comments on this topic
in the August 2, 2007 revised ASC payment system final rule (72 FR
42475), in accordance with section 1833(i)(2)(D)(i) of the Act, we did
take into account the recommendations made in the GAO Report in
developing the final policies for the revised ASC payment system. We
appreciate the public's interest in providing us with detailed input
regarding the revised ASC payment system from a variety of
perspectives. We noted that the GAO's recommendations were in complete
accord with our proposal for the revised ASC payment system (71 FR
49635), and we provided a 90-day comment period on our proposal for CY
2008. We believe that the comment period for the August 23, 2006
proposed rule provided the public with ample opportunity to comment on
the policies that ultimately were recommended by the GAO.
L. Calculation of the ASC Conversion Factor and ASC Payment Rates
1. Overview
As discussed in section XVI.C. of this final rule with comment
period, we finalized our policy to base ASC relative payment weights
and payment rates under the revised ASC payment system on APC groups
and relative payment weights. In the August 2, 2007 revised ASC payment
system final rule, we made final our proposal to set the ASC relative
payment weight for certain office-based surgical procedures so that the
national unadjusted ASC payment rate does not exceed the MPFS
unadjusted nonfacility PE RVU amount. Our final policy is to calculate
ASC payment rates by multiplying the ASC relative payment weights by
the ASC conversion factor. In the August 2, 2007 revised ASC payment
system final rule, our estimate of the CY 2008 budget neutral ASC
conversion factor was $42.542. In the CY 2008 OPPS/ASC proposed rule,
the proposed ASC conversion factor for CY 2008 was $41.400. For this
final rule with comment period, the ASC conversion factor for CY 2008
is $41.401. Although this final ASC conversion factor differs little
from the estimate in the August 2, 2007 revised ASC payment system
final rule and the CY 2008 OPPS/ASC proposed rule, it reflects several
changes, including: (1) Use of the final OPPS relative payment weights
for CY 2008; (2) use of the final MPFS nonfacility PE RVU amounts for
CY 2008; (3) use of updated utilization data from CY 2006; and (4)
application of an adjustment to reflect differences in the geographic
wage adjustment policy between the current and revised systems
(discussed in further detail below). As in the proposed rule, in this
final rule with comment period, we use the final methodology described
in the August 2, 2007 revised ASC payment system final rule (72 FR
42522) to calculate the final CY 2008 ASC conversion factor and the
final ASC relative payment weights and rates.
2. Budget Neutrality Requirement
Section 626(b) of Pub. L. 108-173 amended section 1833(i)(2) of the
Act by adding subparagraph (D) to require that in the year the revised
ASC payment system is implemented:
``[S]uch system shall be designed to result in the same aggregate
amount of expenditures for such services as would be made if this
subparagraph did not apply, as estimated by the Secretary * * *.''
As discussed in the August 2, 2007 revised ASC payment system final
rule, the ASC conversion factor is calculated so that estimated total
Medicare payments under the revised ASC payment system would be budget
neutral to estimated total Medicare payments under the current ASC
payment system as required by the
[[Page 66857]]
statute. That is, application of the ASC conversion factor is designed
to result in aggregate expenditures under the revised ASC payment
system in CY 2008 equal to aggregate expenditures that would have
occurred in CY 2008 in the absence of the revised system, taking into
consideration the cap on payments in CY 2007 as required under section
5103 of Pub. L. 109-171.
We note that we consider the term ``expenditures'' in the context
of the budget neutrality requirement under section 626(b) of Pub. L.
108-173 to mean expenditures from the Medicare Part B Trust Fund. We do
not consider expenditures to include beneficiary coinsurance and
copayments.
3. Calculation of the ASC Payment Rates for CY 2008
The following is a step-by-step illustration of the final budget
neutrality adjustment calculation as finalized in the August 2, 2007
revised ASC payment system final rule and as applied to updated data
available for this final rule with comment period.
The final methodology for establishing budget neutrality under the
revised ASC payment system takes into account a 4-year transition to
full implementation of the revised payment rates and the effects of
several assumptions regarding migration of services across ASCs, HOPDs,
and physicians' offices. Payments during the 4-year transition to the
fully implemented revised ASC payment rates will be based on a blend of
the CY 2007 ASC payment rates and the revised ASC payment rates at 75/
25 in CY 2008, 50/50 in CY 2009, and 25/75 in CY 2010, with payment at
100 percent of the revised ASC payment rates in 2011. The methodology
assumes no net cost or savings to Medicare from the migration of
existing ASC services among ASCs, HOPDs, and physicians' offices. It
includes assumptions that 15 percent of physicians' office utilization
for new ASC procedures, specifically those first added for ASC payment
beginning in CY 2008, will migrate to ASCs over a 4-year period (3.75
percent each year) and that 25 percent of the new procedures' HOPD
utilization will migrate over the first 2 years under the revised
payment system (12.5 percent each year) and accounts for the Medicare
costs and savings associated with that movement. A detailed explanation
of the model may be found in section V.C. of the August 2, 2007 revised
ASC payment system final rule (72 FR 42521).
a. Estimated CY 2008 Medicare Program Payments (Excluding Beneficiary
Coinsurance) Under the Existing ASC Payment System
Step 1: Migration from HOPDs to ASCs is valued using CY 2008 OPPS
payment rates.
(a) We multiply the estimated CY 2008 HOPD utilization for each new
ASC procedure by 0.125, consistent with our assumption that 25 percent
of the HOPD utilization for new ASC procedures will migrate to the ASC
over the first 2 years of the revised ASC payment system, only half of
which would occur in CY 2008. In estimating HOPD utilization for CY
2008, we take into account the impact of the multiple procedure
discount (as discussed in more detail in section V.C.3. the August 2,
2007 revised ASC payment system final rule).
(b) For each new ASC procedure, we multiply the results of Step
1(a) by the CY 2008 OPPS payment rate for the procedure, and then
subtract beneficiary coinsurance for the procedure.
(c) We sum the results of Step 1(b) across all new ASC procedures.
Step 2: Migration of procedures from physicians' offices to ASCs is
valued using CY 2008 physician in-office payment rates. ``Physician in-
office payment rate'' is equal to the MPFS nonfacility PE RVUs
multiplied by the CY 2008 MPFS conversion factor.
(a) We multiply the estimated physician office utilization for CY
2008 for each new ASC procedure by 0.0375, consistent with our
assumption that 15 percent of the physician's office utilization for
new ASC procedures will migrate to the ASC over the full 4-year
transition period.
(b) For each new ASC procedure, we multiply the results of Step
2(a) by the CY 2008 physician in-office payment rate for the procedure,
and then subtract beneficiary coinsurance for the procedure.
(c) We sum the results of Step 2(b) across all new ASC procedures.
Step 3: CY 2007 ASC services are valued using the estimated CY 2008
ASC payment rates under the current ASC system.
To estimate the aggregate expenditures that would be made in CY
2008 under the existing ASC payment system:
(a) We multiply the estimated CY 2008 ASC utilization for each
HCPCS code on the CY 2007 ASC list by the estimated CY 2008 ASC payment
rate for the HCPCS code under the existing ASC payment system, and then
subtract beneficiary coinsurance for the procedure. The estimated CY
2008 ASC payment rates are based on the CY 2007 ASC payment rates,
which were listed in Addendum AA to the CY 2007 OPPS/ASC final rule
with comment period (71 FR 68243 through 68283) and take into account
the OPPS cap on payment for ASC services as required by section 5103 of
Pub. L. 109-171 and reflect the zero percent CY 2008 update for ASC
services mandated by section 1833(i)(2)(C) of the Act. In estimating
ASC utilization for CY 2008, we take into account the impact of the
multiple procedure discount (as discussed in section V.C.3. of the
August 2, 2007 revised ASC payment system final rule).
(b) We estimate the amount the Medicare program would pay in CY
2008 for implantable prosthetic devices and implantable DME for which
ASCs currently receive separate payment under the DMEPOS fee schedule.
(c) We sum the results of Steps 3(a) and 3(b) to estimate the
aggregate amount of expenditures that would be made in CY 2008 for
current covered surgical procedures under the existing ASC payment
system.
Step 4: Sum the results of Steps 1-3. b. Estimated Medicare Program
Payments (Excluding Beneficiary Coinsurance) Under the Revised ASC
Payment System
Step 5: HOPD migration is valued using CY 2008 OPPS payment rates.
This step is the same as Step 1, above.
Step 6: We identify new ASC procedures that are office-based (as
discussed in section III.C. of the August 2, 2007 revised ASC payment
system final rule).
Step 7: Migration of new ASC office-based procedures from
physicians' offices to ASCs is valued based on CY 2008 OPPS payment
rates capped at the CY 2008 physician in-office payment rates, if
appropriate.
(a) For each new ASC procedure determined to be office-based, we
multiply the results of Step 2(a) above by the lesser of--
(1) The CY 2008 OPPS rate for the procedure; or
(2) The CY 2008 physician in-office payment rate for the procedure,
and then subtract beneficiary coinsurance for the procedure.
(b) The results of Step 7(a) are summed across all new ASC
procedures considered to be office based.
Step 8: Migration of new ASC procedures not determined to be
office-based from physicians' offices to ASCs is valued using the CY
2008 OPPS rates.
(a) For each new ASC procedure not considered to be office-based,
we multiply the results of Step 2(a) above by the CY 2008 OPPS rate for
the
[[Page 66858]]
procedure, and then subtract beneficiary coinsurance for the procedure.
(b) The results of Step 8(a) are summed across all new ASC
procedures not considered to be office-based.
Step 9: Migration of new ASC procedures from physicians'' offices
to ASCs is valued using the CY 2008 MPFS physician out-of-office
payment rate. ``Physician out of-office payment rate'' is equal to the
facility PE RVUs multiplied by the CY 2008 MFPS conversion factor.
(a) For each new ASC procedure, we multiply the results of Step
2(a) from above by the CY 2008 physician out-of-office payment rate for
the procedure, and then subtract beneficiary coinsurance for the
procedure.
(b) The results of Step 9(a) are summed across all new ASC
procedures.
Step 10: Current ASC services are valued using the CY 2008 OPPS
payment rates.
To estimate the aggregate amount of expenditures that would be made
in CY 2008, we use CY 2008 OPPS payment amounts instead of estimated CY
2008 ASC payment amounts under the current system, and we multiply the
estimated CY 2008 ASC volume for each HCPCS code on the CY 2007 ASC
list of covered surgical procedures by the CY 2008 OPPS payment rate
for the HCPCS code, and then subtract beneficiary coinsurance for the
procedure. We sum the results over all services on that ASC list.
Step 11: The results of Steps 5 and 7-10 are summed.
c. Calculation of the CY 2008 Budget Neutrality Adjustment
Step 12: The result of Step 4 is divided by the result of Step 11.
Step 13: The application of the cap at the CY 2008 physician in-
office payment rates that occurs in Step 7 is dependent on the ASC
conversion factor. The ASC budget neutrality adjustment resulting from
Step 12 is calibrated to take into account the interactive nature of
the ASC conversion factor and the physician's office payment cap. The
ASC budget neutrality calculation is also calibrated to take into
account the fact that the additional physician out-of-office payment
rates under the revised ASC payment system calculated in Step 9 must be
fully offset by the budget neutrality adjustment to ASC services under
the revised payment system. Furthermore, the budget neutrality
calculation is calibrated to take into account the CY 2008 transitional
payment rates for procedures on the CY 2007 ASC list of covered
surgical procedures.
The application of the above methodology to the data available for
this final rule with comment period results in a budget neutrality
adjustment of 0.65. This number does not differ from the estimated
budget neutrality adjustment of 0.65 for the CY 2008 OPPS/ASC proposed
rule for the revised ASC payment system that was based on partial year
CY 2006 utilization and proposed CY 2008 OPPS and MPFS payment rates
(72 FR 42797).
We built an estimate of differences in total payment created by
differences in the geographic adjustment policy between current and
revised systems into the above model. Medicare currently accounts for
geographic wage variations when calculating individual ASC payments
under the existing payment system by applying the relevant IPPS wage
index values and localities that were established under the IPPS prior
to the implementation of Core Based Statistical Areas (CBSAs) issued by
the Office of Management and Budget in June 2003 to a labor-related
portion of 34.45 percent of the ASC payment amount. As discussed in the
August 2, 2007 revised ASC payment system final rule (72 FR 42518), the
revised payment system will account for geographic wage variations when
calculating individual ASC payments by applying the pre-
reclassification wage index to a labor-related portion of 50 percent of
the ASC payment amount.
In the CY 2008 OPPS/ASC proposed rule, we noted that we did not
have a provider-level dataset of ASC utilization that accurately
identified unique ASCs and their geographic information and that this
prevented us from calculating a budget-neutral wage adjustment. In our
August 2, 2007 revised ASC payment system final rule, we estimated that
the change in the wage policy would not significantly change aggregate
ASC payment. We have since constructed this provider-level database
using several sources to verify the validity of geographic information
on the file. We have also crosswalked deleted HCPCS codes and their
associated utilization to the CY 2008 HCPCS codes. Items previously
paid under the ASC system, for which payment was not adjusted for
differences in labor costs (for example, NTIOLs), were not included in
this analysis. Using this provider-level dataset of CY 2006 ASC claims,
we estimated total CY 2008 payment using revised ASC payment rates, the
existing payment system labor-related portion of 34.45 percent, and the
existing payment system wage index values. Using the same dataset, we
also estimated total CY 2008 payment using revised ASC payment rates, a
labor-related portion of 50 percent, and the pre-reclassification wage
index values based on CBSAs. Comparing the two totals, we calculated an
adjustment of 1.00464, suggesting that the revised wage index values
and labor-related portion would modestly reduce payments under the
revised wage policy compared to the current policy. We built this
adjustment factor into our budget neutrality model to calculate the
final budget neutrality adjustment for the revised ASC payment system.
Incorporating an adjustment for geographic wage differences did not
change the final budget neutrality adjustment.
The final budget neutrality adjustment of 0.65 for the CY 2008
revised ASC payment system reflects updated data, including complete CY
2006 utilization and final CY 2008 OPPS and MPFS payment rates, as well
as the addition of an adjustment for the final geographic wage
adjustment policy of the revised ASC payment system.
d. Calculation of the CY 2008 ASC Payment Rates
After developing the final CY 2008 budget neutrality adjustment of
0.65 according to the policies established in the August 2, 2007
revised ASC payment system final rule, to determine the final CY 2008
ASC conversion factor, we multiplied the final CY 2008 OPPS conversion
factor by the ASC budget neutrality adjustment. The final CY 2008 OPPS
conversion factor is $63.694, and multiplying that by the 0.65 budget
neutrality adjustment yields our final CY 2008 ASC conversion factor of
$41.401. To determine the fully implemented ASC payment rates for this
final rule with comment period, including beneficiary coinsurance,
according to the final payment methodology that applies to most covered
surgical procedures and certain covered ancillary services under the
revised ASC payment system, we multiplied the ASC conversion factor by
the ASC relative payment weight (which equals the OPPS payment weight
in CY 2008) for each procedure or service. As further discussed in
section XVI.C. of this final rule with comment period, the ASC relative
payment weights for certain office-based surgical procedures and
covered ancillary radiology services are set so that the national
unadjusted ASC payment rate does not exceed the MPFS unadjusted
nonfacility PE RVU amount. In addition, the ASC relative payment
weights for device-intensive covered surgical procedures are set
according to a modified payment
[[Page 66859]]
methodology to ensure the same device payment under the revised ASC
payment system as under the OPPS. The CY 2008 ASC payment rates of
covered ancillary drugs and biologicals and brachytherapy sources are
set equal to their final CY 2008 OPPS payment rates, so the ASC
conversion factor is not applicable to these items. We then calculated
the CY 2008 payment rate for procedures on the CY 2007 ASC list of
covered surgical procedures using a blend of 75 percent of the final CY
2007 ASC payment rate and 25 percent of the final CY 2008 ASC payment
rate developed according to the methodology of the revised ASC payment
system, applying the special transition treatment to device-intensive
procedures as discussed in section XVI.C of this final rule with
comment period. We refer readers to Addenda AA and BB to this final
rule with comment period for the final CY 2008 ASC payment weights and
payment rates for covered surgical procedures and covered ancillary
services that are expected to be paid separately under the CY 2008
revised ASC payment system.
4. Calculation of the ASC Payment Rates for CY 2009 and Future Years
a. Updating the ASC Relative Payment Weights
In the August 2, 2007 revised ASC payment system final rule, we
finalized our policy to update the ASC relative payment weights in the
revised ASC payment system each year using the national OPPS relative
payment weights (and MPFS nonfacility PE RVU amounts, as applicable)
for that same calendar year and to uniformly scale the ASC relative
payment weights for each update year to make them budget neutral (72 FR
42531). For example, holding ASC utilization and the mix of services
constant, for CY 2009, we will compare the total weight using the CY
2008 ASC relative payment weights under the 75/25 blend (of the CY 2007
payment rate and the revised payment rate) with the total weight using
CY 2009 relative payment weights under the 50/50 blend (of the CY 2007
payment rate and the revised payment rate), taking into account the
changes in the OPPS relative payment weights between CY 2008 and CY
2009. We will use the ratio of CY 2008 to CY 2009 total weight to scale
the ASC relative payment weights for CY 2009. Scaling of ASC relative
payment weights would apply to covered surgical procedures and covered
ancillary services whose payment rates are related to OPPS relative
payment weights. Scaling would not apply in the case of ASC payment for
separately payable covered ancillary services that have a predetermined
national payment amount (that is, their national payment amounts are
not based on OPPS relative payment weights) such as drugs and
biologicals that are separately paid under the OPPS. Any service with a
predetermined national payment amount would be included in the budget
neutrality comparison, but scaling of the relative payment weights
would not apply to those services. The ASC payment weights for those
services without predetermined national payment amounts (that is, their
national payment amounts would be based on OPPS relative payment
weights if a payment limitation did not apply) would be scaled to
eliminate any difference in the total payment weight between the
current year and the update year.
b. Updating the ASC Conversion Factor
Section 1833(i)(2)(C) of the Act requires that, if the Secretary
has not updated the ASC payment amounts in a calendar year after CY
2009, the payment amounts shall be increased by the percentage increase
in the CPI-U as estimated by the Secretary for the 12-month period
ending with the midpoint of the year involved. Therefore, as discussed
in the August 2, 2007 revised ASC payment system final rule, we adopted
a final policy to update the ASC conversion factor using the CPI-U in
order to adjust ASC payment rates for inflation (72 FR 42518). We will
implement the annual updates through an adjustment to the conversion
factor under the revised ASC payment system, beginning in CY 2010 when
the statutory requirement for a zero update no longer applies.
We received a number of public comments regarding the update of the
ASC conversion factor using the CPI-U. A summary of the public comments
and our responses follow.
Comment: Several commenters were concerned that updating the
conversion factor for the revised ASC payment system using the CPI-U
would cause divergence in the relationship between payment to HOPDs
(the OPPS is updated annually as the statute requires, using the
hospital market basket percentage increase, as described in section
II.C. of this final rule with comment period) and ASCs over time that
would not be based on growing differences between the costs of
providing procedures in those two different settings. The commenters
believed that hospitals and ASCs experienced similar inflationary
pressures. Therefore, they recommended that CMS use the hospital market
basket as the update for inflation under the revised ASC payment system
because that update would more appropriately reflect inflation in the
costs of providing surgical services. In addition, the commenters
believed that the same update under the two payment systems would allow
for a consistent relationship between their payment for the same
surgical procedures.
Response: While we appreciate the commenters' concerns, the update
policy for the revised ASC payment system was not open to comment in
the CY 2008 OPPS/ASC proposed rule because we finalized that policy in
the August 2, 2007 revised ASC payment system final rule after we
received and addressed public comments (72 FR 42519). Beginning in CY
2010, when the period of the zero update for ASCs that the statute
requires ends, we will apply the CPI-U to update the ASC conversion
factor for inflation under the revised ASC payment system.
M. Annual Updates
Under the revised ASC payment system, we update on an annual
calendar year basis the ASC conversion factor, the relative payment
weights and APC assignments, the ASC payment rates, and the list of
procedures for which Medicare would not make ASC payment. To the extent
possible under the rules and policies of the revised ASC payment
system, we maintain consistency between the OPPS and the ASC payment
system in the way we treat new and revised HCPCS and CPT codes for
payment under the ASC payment system. We also will invite comment as
part of the annual update cycle to determine if there are procedures
that we exclude from payment in the ASC setting that merit
reconsideration as a result of changes in clinical practice or
innovations in technology.
We update the ASC list of covered surgical procedures and payment
system as part of the annual proposed and final rulemaking cycle
updating the hospital OPPS. We believe that including the ASC update as
part of the OPPS rulemaking cycle will ensure that updates of the ASC
payment rates and the list of covered surgical procedures for which
Medicare makes payment to ASCs will be issued in a regular,
predictable, and timely manner. Moreover, the ASC payment system will
be updated concurrent with changes in the APC groups and the OPPS
inpatient list, making it easier to predict changes in payment for
particular services from year to year.
[[Page 66860]]
In addition, we evaluate each year all new HCPCS codes that
describe surgical procedures to make preliminary determinations
regarding whether or not they should be payable in the ASC setting and,
if so, whether they are office-based procedures. In the absence of
claims data that would indicate where procedures described by new codes
are being performed and identify the facility resources required to
perform them, we proposed to use other available information, including
our clinical advisors' judgment, predecessor CPT and Level II HCPCS
codes, information submitted by representatives of specialty societies
and professional associations, and information submitted by commenters
during the public comment period following publication of the final
rule with comment period in the Federal Register. We publish in the
annual OPPS/ASC payment update final rule those interim determinations
for the new codes to be active January 1 of the update year. The ASC
payment system treatment of those procedures will be open to comment on
that final rule, and we will respond to comments about our interim
determinations in the OPPS/ASC final rule for the following year. After
our review of public comments and in the absence of physicians' claims
data, if our determination regarding a new code was that it should be
included on the ASC list of covered surgical procedures as an office
based procedure subject to the payment limitation, this determination
would remain preliminary until we are able to consider more recent
volume and utilization data for each individual procedure code or, if
appropriate, the clinical characteristics, utilization, and volume of
related codes. Using that information, if we confirm our determination
that the new code was appropriately assigned to an office-based payment
indicator, it will then be permanently assigned to the list of office-
based procedures subject to the payment limitation.
Accordingly, this annual rulemaking and publication of revised
payment methodologies and payment rates are reflected in Sec. 416.173
of the regulations.
Comment: A few commenters urged us to complete the alignment of the
OPPS and ASC by migrating from the CMS-1500 form to the UB-04 billing
form for ASC claims submission, the same claim form that is used by
HOPDs for Medicare payment and by ASCs for some other payers. They
recommended that CMS initiate a transition process for providers and
the agency's administrative contractors to implement the UB-04 form for
ASCs in CY 2010. The commenters stated that during CYs 2008 and 2009
ASCs would gain experience with the revised payment system and
reporting quality measures and by CY 2010 could be ready to adopt the
UB-04 for submitting their Medicare claims.
Response: This same comment was addressed in the August 2, 2007
revised ASC payment system final rule (72 FR 42534). As we discussed in
that final rule, we will explore the feasibility of adopting the ASC
billing change recommended by commenters. We reiterate here that a
policy change that requires ASCs to use a different billing format
would have to allow adequate time for CMS and ASCs to make the
necessary systems changes and for CMS to provide training for
contractors and ASCs prior to implementing the new format. We plan to
pursue the feasibility of this option and to coordinate any possible
change to ASC billing requirements with CMS'' overall contracting
transition. We welcome additional information from the public regarding
recommendations for ASC billing modifications or improvements that we
should consider once the revised payment system is implemented.
XVII. Reporting Quality Data for Annual Payment Rate Updates
A. Background
1. Reporting Hospital Outpatient Quality Data for Annual Payment Update
Section 109(a) of the MIEA-TRHCA (Pub. L. 109 432) amended section
1833(t) of the Act by adding a new subsection (17) that affects the
payment rate update applicable to OPPS payments for services furnished
by hospitals in outpatient settings on or after January 1, 2009. New
section 1833(t)(17)(A) of the Act, which applies to hospitals as
defined under section 1886(d)(1)(B) of the Act, requires that hospitals
that fail to report data required for the quality measures selected by
the Secretary in the form and manner required by the Secretary under
section 1833(t)(17)(B) of the Act will incur a reduction in their
annual payment update factor by 2.0 percentage points. New section
1833(t)(17)(B) of the Act requires that hospitals submit quality data
in a form and manner, and at a time that the Secretary specifies. New
sections 1833(t)(17)(C)(i) and (ii) of the Act require the Secretary to
develop measures appropriate for the measurement of the quality of care
(including medication errors) furnished by hospitals in outpatient
settings and that these measures reflect consensus among affected
parties and, to the extent feasible and practicable, include measures
set forth by one or more national consensus building entities. The
Secretary is not prevented from selecting measures that are the same as
(or a subset of) the measures for which data are required to be
submitted under section 1886(b)(3)(B)(viii) of the Act for the IPPS
Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU)
program. New section 1833(t)(17)(D) of the Act gives the Secretary the
authority to replace measures or indicators as appropriate, such as
when all hospitals are effectively in compliance or when the measures
or indicators have been subsequently shown not to represent the best
clinical practice. New section 1833(t)(17)(E) of the Act requires the
Secretary to establish procedures for making data submitted available
to the public. Such procedures must give hospitals the opportunity to
review data before these data are released.
In the CY 2007 OPPS/ASC final rule with comment period (71 FR
68189), we indicated our intent to establish, in CY 2009, an OPPS
RHQDAPU program modeled after the current IPPS RHQDAPU program. We
stated our belief 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. We agreed 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. We stated our intent to
condition the full OPPS payment rate update beginning in CY 2009 based
upon hospital reporting of quality data beginning in CY 2008, using
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.
The amendments to the Act made by section 109(a) of the MIEA-TRHCA
are consistent with our intent and direction outlined in the CY 2007
OPPS/ASC final rule with comment period. Under these amendments, we are
now statutorily required to establish a program under which hospitals
will report data on the quality of hospital outpatient care using
standardized measures of care in order to receive the full annual
update to the OPPS payment rate, effective for payments beginning in CY
2009. We will refer to the program established under these amendments
as
[[Page 66861]]
the Hospital Outpatient Quality Data Reporting Program (HOP QDRP).
In reviewing the measures currently available for care in the
hospital outpatient settings, we continue to believe that it would be
most appropriate and desirable to use measures that have been
specifically developed for application in the hospital outpatient
setting. Although we still believe that hospitals generally function as
integrated systems in inpatient and outpatient settings, we do not
believe it is appropriate to use participation in the IPPS RHQDAPU
program for the purpose of implementing section 1833(t)(17) of the Act
in the hospital outpatient setting. Nonetheless, section
1833(t)(17)(C)(ii) of the Act indicates that the Secretary is not
prevented ``from selecting measures that are the same as (or a subset
of) the measures for which data are required to be submitted'' under
the IPPS RHQDAPU program. In the CY 2008 OPPS/ASC proposed rule (72 FR
42799), we proposed to establish a separate reporting program and
proposed quality measures that are appropriate for measuring hospital
outpatient quality of care, that reflect consensus among affected
parties, and are set forth by one or more of the national consensus
building entities.
2. Reporting ASC Quality Data for Annual Payment Increase
Section 109(b) of the MIEA-TRHCA, Pub. L. 109-432 amended section
1833(i) of the Act by adding new sections 1833(i)(2)(D)(iv) and
1833(i)(7) to the Act. These amendments may affect ASC payments for
services furnished in ASC settings on or after January 1, 2009. New
section 1833(i)(2)(D)(iv) of the Act authorizes the Secretary to
implement the revised payment system for services furnished in ASCs
(established under section 1833(i)(2)(D) of the Act), ``so as to
provide for a reduction in any annual payment increase for failure to
report on quality measures.''
New section 1833(i)(7)(A) of the Act authorizes the Secretary to
provide that any ASC that fails to report data required for the quality
measures selected by the Secretary in the form and manner required by
the Secretary under new section 1833(i)(7) of the Act will incur a
reduction in any annual payment increase of 2.0 percentage points. New
section 1833(i)(7)(A) of the Act also specifies that a reduction for
one year cannot be taken into account in computing the ASC update for a
subsequent year.
New section 1833(i)(7)(B) of the Act provides that, ``except as the
Secretary may otherwise provide,'' the hospital outpatient quality data
provisions of section 1833(t)(17)(B) through (E) of the Act, summarized
above, shall apply to ASCs.
We refer readers to section XVII.I. of this final rule with comment
period for a discussion of our decision to introduce implementation of
ASC quality data reporting in a later rulemaking.
3. Reporting Hospital Inpatient Quality Data for Annual Payment Update
Section 5001(a) of the Deficit Reduction Act of 2005, Pub. L. 109-
171, set out the current requirements for the IPPS RHQDAPU program. We
established the RHQDAPU program in order to implement section 501(b) of
Pub. L. 108-173. The program builds on our ongoing voluntary Hospital
Quality Initiative. The Initiative is intended to empower consumers
with quality of care information so that they can make more informed
decisions about their health care while also encouraging hospitals and
clinicians to improve the quality of their care. Under the current
statutory provisions found in section 1886(b)(3)(B)(viii) of the Act,
the IPPS annual payment update for ``subsection (d)'' hospitals that do
not submit inpatient quality data in a form, and manner, and at a time
specified by the Secretary is reduced by 2.0 percentage points.
We used an initial ``starter set'' of 10 quality measures for the
IPPS RHQDAPU program under section 501(b) of Pub. L. 108-173 and have
expanded the measures as required under section
1886(b)(3)(B)(viii)((IV) and (V) of the Act, as added by section
5001(a) of Pub. L. 109-171. We initially added measures as a part of
the annual IPPS rulemaking process. In response to public comments
asking that we issue IPPS RHQDAPU program quality measures and other
requirements as far in advance as possible, we also have used the OPPS
annual payment update rulemaking process to adopt IPPS RHQDAPU program
measures and requirements. In the CY 2007 OPPS final rule (71 FR
68201), we added six additional IPPS RHQDAPU program quality measures
for FY 2008 update.
Most recently, in the FY 2008 IPPS proposed rule (72 FR 24805), we
proposed adding 5 additional quality measures in for the FY 2009
update. However, in the FY 2008 IPPS final rule with comment period (72
FR 47351), we only adopted one of the proposed additional five
measures. We indicated that we intended to adopt three additional
measures in this CY 2008 OPPS/ASC final rule with comment period, but
only if the measures were adopted by the National Quality Forum (NQF).
The NQF is a voluntary consensus standard-setting organization
established to standardize health care quality measurement and
reporting through its consensus development process. Under section
1886(b)(3)(B)(viii)(V) of the Act, we are required, to the extent
feasible and practicable, to use measures set forth by entities such as
NQF when adding new measures.
Section XVII.J. of this final rule with comment period contains a
discussion of our decision to add two additional NQF-endorsed quality
measures to the IPPS RHQDAPU program, with reporting to begin with the
first calendar quarter of 2008 discharges, for the FY 2009 annual
payment update.
B. Hospital Outpatient Measures
For the initial implementation of the HOP QDRP, we proposed 10
quality measures that we believed to be both applicable to care
provided in hospital outpatient settings and likely to be sufficiently
developed to permit data collection consistent with the timeframes
defined by statute. These measures address care provided to a large
number of adult patients in hospital outpatient settings, across a
diverse set of conditions, and were selected for the initial set of HOP
QDRP measures based on their relevance as a set to all hospitals.
The first five of these measures capture the quality of outpatient
care in hospital emergency departments (EDs), specifically for those
adult patients with acute myocardial infarction (AMI) who are treated
and then transferred to another facility for further care. These
patients receive many of the same interventions as patients who are
evaluated and admitted at the same facility, whose care is currently
assessed in measures that are endorsed by the National Quality Forum
(NQF). NQF is a voluntary consensus standard setting organization
established to standardize health care quality measurement and
reporting through its consensus development process. Moreover, these
are also inpatient AMI measures that have long been reported under the
IPPS RHQDAPU program, and are published on the Hospital Compare Web
site at: www.HospitalCompare.hhs.gov.
Transferred AMI patients historically have not been included with
the directly-admitted patients for purposes of the calculation of the
inpatient AMI measures because of differences in data collection and
reporting for the two groups. With the input of provider and
practitioner experts in the field, we
[[Page 66862]]
developed specifications for related emergency department transfer
measures that, while consistent with the measure specifications for the
related hospital inpatient measures, reflect the unique operational and
clinical aspects of care in hospital outpatient settings. The processes
of care encompassed by these measures address care on arrival, the
promptness of interventions, and discharge care for patients presenting
to a hospital with an AMI.
In addition to the five ED-AMI measures, CMS identified five
quality measures that were directly related to conditions treated or
interventions provided in hospital outpatient settings and that we
believed were also appropriate and fully developed for use in the HOP
QDRP. These measures were specified in a form that assessed the care
provided by physicians, however, these measures are also relevant to
assessing care at the facility level. CMS was engaged in reviewing, and
where appropriate, revising these measure specifications so that they
explicitly assess care provided in hospital outpatient settings. he
five measures included one measure related to treatment of heart
failure, two measures related to surgical care improvement, one measure
addressing treatment of community-acquired pneumonia, and one measure
related to diabetes care.
Therefore, for hospitals to receive the full OPPS payment update
for services furnished in CY 2009, in the CY 2008 OPPS/ASC proposed
rule (72 FR 42800) we proposed to require that hospital outpatient
settings submit data on the following 10 measures, effective with
hospital outpatient services furnished on or after January 1, 2008.
ED-AMI-1--Aspirin at Arrival.
ED-AMI-2--Median Time to Fibrinolysis.
ED-AMI-3--Fibrinolytic Therapy Received Within 30 Minutes
of Arrival.
ED-AMI-4--Median Time to Electrocardiogram (ECG).
ED-AMI-5--Median Time to Transfer for Primary PCI.
PQRI 5 Heart Failure: Angiotensin-Converting
Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy
for Left Ventricular Systolic Dysfunction (LVSD).
PQRI 20 Perioperative Care: Timing of Antibiotic
Prophylaxis.
PQRI 21 Perioperative Care: Selection of
Prophylactic Antibiotic.
PQRI 59 Empiric Antibiotic for Community-Acquired
Pneumonia.
PQRI 1 Hemoglobin A1c Poor Control in Type 1 or 2
Diabetes Mellitus.
As required by statute, consensus was reached by affected parties,
as the measures were identified as appropriate for reporting on
hospital outpatient care in collaboration with professionals and
providers with experience in hospital outpatient settings as well as
with the Hospital Quality Alliance (HQA), a hospital-industry led,
public-private collaboration established to promote public reporting on
hospital quality of care. The specifications for outpatient measures
were then completed for hospital data collection using the same format
that is used for inpatient measures. CMS finalized the specifications
for these 10 measures and released them publicly on August 28, 2007. In
addition these 10 measures have gone through the NQF steering committee
process.
Nine of the ten proposed measures are process measures, while one
measure--Hemoglobin A1c >9.0 percent--is an intermediate outcome
measure that has not been risk adjusted. While poor quality of care can
lead to poor diabetes control and elevated A1c levels, CMS recognizes
that patient noncompliance with prescribed treatment regimen can also
lead to poor diabetes control and elevated A1c levels. Patients with
comorbidities or diabetes complications may also have a harder time
controlling their diabetes and thus have higher A1c levels. Therefore,
we specifically requested comments on this intermediate outcome measure
and whether it may lead to unintended consequences.
CMS believes that an A1c level higher than 9.0 percent represents a
level of control that is sufficiently poor enough that it should not
result in any unintended consequences. The scientific literature would
suggest that an A1c level of 8.0 percent or less might represent the
best control that could be expected for some patients: therefore, CMS
believes that an A1c level of > 9.0 percent represents a level of
control that is poor enough that risk-adjustment is not warranted.
Additionally, this A1c measure was endorsed by the National Quality
Forum (NQF) in 2006. One of the criteria for evaluation of measures
within the NQF process is ``scientific acceptability,'' which includes
appropriate risk-adjustment. Some measures are not endorsed by NQF if
risk-adjustment is determined to be appropriate and is found to be
inadequate. CMS believes that additional risk-adjustment is not
necessary because the NQF endorsed this measure. We invited public
comment on our rationale for choosing a diabetes outcome measure rather
than a process measure.
Comment: Several commenters supported collecting quality measure
data for outpatient hospital services. Several commenters agreed with
not using any inpatient quality measures for the outpatient hospital
setting. One commenter stated that the proposed indicators are things
that providers should be achieving for patients, and if done correctly,
this endeavor will help to drive down the overall expenditures in
health care.
Response: We thank the commenters for their support.
Comment: Several commenters supported the emergency room measures.
However, the commenters also expressed concern that these measures
would most affect smaller facilities that may not have the resources
required for such data collection. One commenter stated that its
facility does not transfer such patients and would not have any data
for this set of measures.
Response: We appreciate the support expressed by commenters for the
five ED-AMI measures. We agree that these measures will mostly apply to
smaller facilities that do not admit such patients, transferring them
instead. In fact, these measures were designed specifically for smaller
facilities that were not included under quality measure reporting for
inpatient measures. We recognize that some facilities, usually larger
ones, do not transfer such patients; information on these patients for
these facilities is captured under quality measure reporting for
inpatient measures. Including the five ED-AMI measures in the required
measure set for HOP QDRP will allow smaller facilities the opportunity
to report quality measure data. We acknowledge that there are resource
costs associated with collecting quality measure data, however, we also
view it important that an opportunity to report such data be provided
to smaller facilities and that consumers have information available
from this type of facility. There is no penalty for not reporting
quality measure data in the event that the provider does not have
relevant cases.
Comment: One commenter did not support the use of the ED-AMI-4-
Median Time to Electrocardiogram as this measure has not been adopted
by NQF, nor is it collected for inpatients and, thus, is not ready for
reporting.
Response: As statutorily required, affected parties reached
consensus on the 10 proposed quality measures for outpatient hospital
services. In addition, the ED-AMI-4 measure has been submitted for NQF
endorsement with the other ED-AMI measures; all of these
[[Page 66863]]
measures have gone through the NQF steering committee process and have
been recommended for endorsement.
Comment: One commenter expressed concern that for the five ED-AMI
measures, the specifications contain no mention of observation
patients.
Response: Observation care is a well-defined set of specific,
clinically appropriate services, which include ongoing short-term
treatment, assessment, and reassessment, before a decision can be made
regarding whether a patient will require further treatment as a
hospital inpatient. Observation status is commonly assigned to patients
who present to the emergency room. Thus, the five ED-AMI measures are
specifically designed to capture care rendered to such patients;
patients that receive care but are not admitted as inpatients, that is,
have outpatient status.
Comment: Many comments addressed the use of the Hemoglobin A1c
measure. Several commenters expressed opinions ranging from concern
with to strong opposition to the use of the Hemoglobin A1c measure for
measuring outpatient hospital quality of care. While agreeing with the
importance of hemoglobin A1c levels as a clinical measure for diabetes
care, some commenters viewed this as more reflective of physician care
and patient compliance. As the proposed Hemoglobin A1c measure is an
outcome measure that is not risk adjusted; the need to use only process
measures or risk adjust any outcome measures was also stated. One
commenter agreed with the use of the proposed Hemoglobin A1c measure
and that this measure did not require risk adjustment, but stated that
this measure does need definition of the expected frequency of what the
inclusion and exclusion criteria are. One commenter supported the
Hemoglobin A1c measure but suggested a revision to being <7 percent,
consistent with clinical guidelines.
Response: We agree with these comments regarding the Hemoglobin A1c
measure. As noted in the proposed rule, the Hemoglobin A1c measure is
an intermediate outcome measure that has not been risk adjusted.
Recognizing the individual patient challenges with regard to this
measure, as well as the need to otherwise modify the measure, we will
not include the Hemoglobin A1c measure in the final HOP QDRP measure
set at this time.
Comment: Several commenters stated that, except for the ED
patients, it was unclear what the patient populations of interest are
under the proposed outpatient hospital measures. For example, surgery
patients could come from several areas of the hospital and PQRI
1 and 5 could apply to outpatients that present for
services unrelated to their conditions. Two commenters expressed
concerns about patients that walk out from the ED and requested that
these patients be excluded from any ED measures.
Response: As discussed previously and noted below, data collection
on the PQRI 1 measure will not be required for any CY 2009 HOP
QDRP determinations. We thank the commenters for raising the issue of
patients that walk out from the ED and will consider this issue in the
formulation of future measure specifications. We are also concerned
about the comments received concerning the administrative burden for
collection on PQRI 5-Heart failure and PQRI 59-
communicty acquired pneumonia. We agree with the commenters that, at
this point, those proposed quality measures may not be sufficiently
refined for use in the outpatient setting. Therefore, we are not
adopting PQRI 5 and PQRI 59 at this point as quality
measures for the HOP QDRP.
Comment: Several commenters disagreed with the use of any or all of
the five, non-ED-AMI measures as measures of quality of care for
hospital outpatient services on the grounds that these measures were
more indicative of the care provided by other settings, especially
physician practices.
Response: We acknowledge that the five non-ED AMI measures were
initially developed for measurement of quality of care provided by
physician practices, and are all part of CMS'' physician quality
reporting initiative. However, the two surgical infection prevention
measures would also apply to patients who have surgery in the hospital
outpatient department. The diabetes measure and the heart failure
measure apply to hospital outpatient department clinics that provide
primary care services, and the pneumonia measure applies to hospital
outpatient clinic departments and patients who are seen in an emergency
department and discharged to home from the ED. Thus, it is our view
that all of these measures could be fairly applied to hospital
outpatient services as these patients are seen and services are
rendered in this setting. However, in understanding of various concerns
with some of these measures, we have decided to not include collection
of data for the proposed heart failure, pneumonia, and diabetes
measures as discussed in this section, for making HOP QDRP decisions
for the CY 2009 payment update determinations. Data for the two
perioperative care measures will be required.
Comment: Commenters supported some of the non-ED measures. One
commenter stated that perioperative care and timing of antibiotics
(PQRI 20) are currently captured for inpatients and would be
suitable reporting indicators for outpatient surgical cases if
hospitals are provided specific surgical procedures to be included, are
informed whether interventional procedures would be included, and are
notified which prophylactic antibiotics would be included. One
commenter stated that the proposed pneumonia measure was logical for
measuring quality of care related to antibiotic administration in the
ED and for patients under observation status.
Response: We thank the commenters for their support of these
quality measures and intend to provide necessary specifications for
data collection. At this time, there are no requirements to sample
cases for the perioperative care measures by surgery type and thus
there is no need to separate out specific surgical procedures for the
purposes of selecting cases for the perioperative measures.
Comment: Several commenters expressed concern about the
administrative and financial burden that would be associated with
collecting outpatient hospital quality measure data, and indicated that
the effort to be expended to collect such information would outweigh
the benefit of this collection. Two commenters stated that data should
be collected to improve clinical practice not just for payment
purposes.
Response: We recognize that there are administrative and financial
costs associated with collecting quality measure data. The reporting of
quality measures for hospital outpatient services builds on our
previous efforts in the inpatient arena, having the same purpose.
Reporting is intended to encourage hospitals and clinicians to improve
their quality of care and to empower consumers with quality of care
information to make more informed decisions about their health care. We
also note the requirement to report hospital outpatient quality measure
data is statutory with the payment implication contingent upon the
reporting of such information.
Comment: Several commenters stated that the infrastructure did not
exist to support collecting outpatient hospital data as it did for
collecting inpatient hospital data. The commenters stated that it would
be extremely difficult if not impossible to meet the
[[Page 66864]]
implementation timeline due to the complexities of building data
collection information systems. In particular, some of the commenters
pointed out differences in storage of outpatient hospital services
information and the possible need to connect information systems and
people from different parts of a hospital and the lack of existing
vendors as important differences.
Response: We recognize that the data infrastructure necessary to
support collecting outpatient hospital data varies considerably among
hospitals. To lessen the burden associated with this effort and
recognizing the need for further refinement of some of the proposed
measures for the outpatient setting, we have reduced the number of
required measures and delayed implementation as discussed later in this
final rule with comment period. Also, to aid hospitals in collecting
these data, we will be providing a data collection tool in sufficient
advance timing of required data submission.
Comment: Several commenters expressed concerns for training/
support. For example, the commenters asked if a Quest or Quest-like
entity would be provided and whether QIOs would be involved for the HOP
QDRP. One commenter urged that QIOs be involved in providing support to
hospitals for the HOP QDRP.
Response: We recognize the need for hospital support under the HOP
QDRP. It is our intent that a Quest or Quest-like entity be provided to
support this effort. In addition, we are in the process of procuring a
contractor to assist in supporting implementation of HOP QDRP. Under
the initial implementation of the HOP QDRP, there will be no QIO
involvement.
Comment: Several commenters asked questions related to the source
of required data, in particular, what claim submission form would be
the data source, what is the definition of outpatient hospital
services, what is the population or universe for sampling purposes,
what is considered a hospital-based outpatient clinic (for example if a
hospital owns an outside clinic, are these cases included or are only
the clinics within the hospital to be included).
Response: Under MIEA-TRCHA, Quality Measure Reporting for
Outpatient Hospital Services applies to ``subsection (d)'' hospitals
subject to the OPPS. The Medicare Benefit Policy Manual, Chapter 6,
under Hospital Services Covered Under Part B, provides the following
definition of ``hospital outpatient'': ``A hospital outpatient is a
person who has not been admitted by the hospital as an inpatient but is
registered on the hospital records as an outpatient and received
services (rather than supplies alone) from the hospital.'' Under this
definition, such services must be directly received from the hospital.
Thus, the population of interest consists of services rendered to
Medicare beneficiaries reimbursed to hospitals under the OPPS or
comparable services rendered under other payers. For Medicare
beneficiaries, the claims data source for this information would be the
UB-04, formally known as the UB-92. The UB-04 is a uniform
institutional provider bill suitable for use in billing multiple third
party payers. All other information necessary would come from the
medical record.
Comment: Several commenters asked when the algorithms used for the
measures would be available for review. In particular, they asked if
the algorithms would be available for review at least 120 days prior to
any start date to allow for vendor programming.
Response: The measure specifications were posted on August 28,
2007, far in advance of any proposed data reporting requirements. The
following Web site includes the 10 proposed Hospital Outpatient (HOP)
Measures: http://www.cms.hhs.gov/QualityInitiativesGenInfo/01--
overview.asp. These measure specifications are final for April 2008
discharges forward. As discussed later in this section, data collection
will begin with services rendered beginning April 2008 rather than
beginning January 2008. From our perspective, the specifications for
the final HOP measures finalized in this final rule with comment period
are ready to use for programming purposes. It is possible that we will
issue a revised version of the measure specifications for services
after April 2008, but sufficient time for programming and data
submission will be allowed.
Comment: One commenter asked whether vendor tools would be required
to have reporting capabilities.
Response: We do not supply external vendors with requirements; we
provide the measure specifications. We will consider providing such
functionality in any reporting tool supplied by CMS.
Comment: Several commenters asked whether critical access hospitals
would be required to report quality measures for hospital outpatient
services. One commenter stated that critical access hospitals should be
required to report data on the five ED-AMI measures proposed.
Response: The statute specifically notes the entities subject to
the reporting quality measure data requirement for OPPS annual payment
updates. Section 1833(t)(17)(A)(i) of the Act, as added by section
109(a) of the MIEA-TRHCA (Pub. L. 109-432), requires a 2.0 percentage
point reduction to the OPPS conversion factor update for those
``subsection (d)'' hospitals that do not submit to the Secretary data
required to be submitted on measures selected in a form and manner, and
at a time, specified by the Secretary. Subsection (d) hospitals are
defined in section 1886(d)(1)(B) of the Act and do not include critical
access hospitals. Additionally, outpatient hospital services at
critical access hospitals are not reimbursed under the OPPS, so a
reduction in the OPPS update factor would not affect critical access
hospitals.
Comment: Several commenters asked whether the proposed payment
reduction would apply to all services reported in CY 2009.
Response: As stated in the statute, the payment reduction would
affect the annual OPPS payment increase by 2.0 percentage points. Thus,
all hospital outpatient services subject to this update would be
affected.
Comment: Several commenters urged CMS to not proceed with
implementation of measures that have not received NQF endorsement and
to wait until HQA finalizes their list of measures; field testing of
measures was also recommended.
Response: The statute requires that we develop measures appropriate
for the measurement of the quality of care furnished by hospitals in
outpatient settings and that these measures reflect consensus among
affected parties and, to the extent feasible and practicable, we
include measures set forth by one or more national consensus building
entities. The five ED-AMI measures address care provided to outpatients
that receive many of the same interventions as inpatients who are
evaluated and admitted at the same facility, and whose care is
currently assessed in measures that are endorsed by NQF. Also, these
five ED-AMI measures are inpatient AMI measures that have long been
reported under the IPPS RHQDAPU program. As of the publication of this
final rule with comment period, the two perioperative measures,
Perioperative Care: Timing of Antibiotic Prophylaxis and Perioperative
Care: Selection of Prophylactic Antibiotic, have received NQF
endorsement. As discussed in this final rule with comment period, data
collection for the remaining three proposed measures for heart failure,
pneumonia, and diabetes mellitus will
[[Page 66865]]
not be required for CY 2009 payment decisions.
We utilize field-testing to the extent it is feasible and
practical. The five ED-AMI transfer measures have been extensively
tested for use in the inpatient setting. We have removed the transfer
exclusion in order to incorporate the ED-AMI measure into the
outpatient hospital setting. We believe the five ED-AMI measures are
optimal for use in the outpatient hospital setting and will help
fulfill our MIEA-TRCHA requirements for outpatient quality measure
reporting. We intend to begin additional field testing in November 2007
and plan to make changes as necessary to specifications for future
reporting.
Comment: One commenter recommended that any CMS-supplied tool
should have separate modules for inpatient and outpatient data
collection and reporting.
Response: It is our intent that the CMS-supplied tool will have
separate modules for inpatient and outpatient data collection and
reporting.
Comment: Several commenters noted that in the specifications of the
two surgical measures in the Specifications Manual for hospital
outpatient measures, CPT codes as opposed to ICD-9 codes were used to
define the relevant procedures and questioned this approach. Several
commenters also suggested that for any NQF-endorsed measures, the ``all
codes'' versions should be used.
Response: CPT, E/M (Evaluation and Management) and ICD-9-CM Codes
are used to identify eligible cases in the outpatient measures. Because
the set of measures crosses settings (clinic, emergency department,
hospital outpatient surgery department), it is necessary to utilize a
variety of codes to adequately capture and sample the appropriate
populations. For the surgical measures, each procedure is assigned a
CPT code on the claim form and hospitals will use this information to
pull the charts to be abstracted. The CPT-4 is a uniform coding system
consisting of descriptive terms and identifying codes that are used
primarily to identify medical services and procedures furnished by
physicians and other health care professionals. More information
regarding coding can be found on the CMS Web site at: http://www.cms.hhs.gov/MedHCPCSGenInfo/20--HCPCS--Coding--Questions.asp.
Comment: Several commenters expressed concerns about OPPS data
reliability due to coding disparities from the high volume of many
closely related codes.
Response: We understand the complexities of coding for outpatient
services and have designed specifications with this in consideration.
While data validation will not be used in the CY 2009 HOP QDRP
determinations, as discussed below, future validation efforts can help
to reduce coding disparities.
After consideration of the public comments received and as
discussed in the above responses to those comments, for the CY 2009
annual payment update we are requiring HOP QDRP reporting using 7 of
the proposed measures--the five ED-AMI measures as well as the two
Perioperative Care measures, PQRI 20 Perioperative Care:
Timing of Antibiotic Prophylaxis and PQRI 21 Perioperative
Care: Selection of Prophylactic Antibiotic. As noted previously, we
have decided to not implement three of the proposed measures,
specifically those related to heart failure, diabetes, and community-
acquired pneumonia for CY 2009 payment decisions. These decisions are
based upon the recognition of the burden placed on providers in
developing systems to collect outpatient quality measure data and need
to utilize quality measures sufficiently refined for use in the
outpatient setting.
C. Other Hospital Outpatient Measures
In addition to the 10 measures discussed above, we are considering
a number of other possible quality measures for use in assessing the
care provided by hospital outpatient settings, for the HOP QDRP
determinations for CY 2010 or subsequent calendar year payment updates.
These measures are, for the most part, either currently in use or were
developed for use in settings other than hospital outpatient. However,
we believe that these measures are applicable to the hospital
outpatient settings.
These measures have not received formal review by either the HQA or
the NQF as measures of HOP performance. As noted in the chart, however,
the inpatient or ambulatory versions of these measures have all been
either recommended by an NQF subgroup for endorsement, are pending
endorsement by the NQF, or are currently endorsed by the NQF. The
measures present the diversity of services and clinical topics provided
to adult patients in hospital outpatient settings. The measures address
some aspects of care provided to cancer patients, patients presenting
with diabetes, pneumonia, chest pains, syncope, or depression, and
patients receiving services related to bones, eyes, and problems
associated with aging. While some of the measures relate to acute care
provided in a hospital outpatient setting, others assess care that a
hospital outpatient clinic might provide on an ongoing basis. In the CY
2008 OPPS/ASC proposed rule, (72 FR 42801), we expressed interest in
receiving comments from the public concerning all dimensions of these
measures.
We expect that once the HOP QDRP is established, we will expand the
set of measures on which hospital outpatient settings must report data.
In the CY 2008 OPPS/ASC proposed rule, (72 FR 42801), we also expressed
interest in receiving comments concerning the relative priority that
should be assigned to each of the measures or topics identified in the
list below, as well as any additional measures, measure sets, or topics
that should be developed for future reporting.
We would like to note that, while we are committed to identifying
measures that are relevant to care in hospital outpatient settings, it
is also our intent to develop, where feasible, hospital outpatient
measures that are ``harmonized'' with measures for assessing comparable
inpatient and ambulatory care--that is, measures that are similar in
both the care that is assessed and the manner in which data are
collected, regardless of the setting. The goal of harmonization is to
assure that comparable care in different care settings can be evaluated
in similar ways, which further assures that quality measurement and
improvement can focus more on the needs of a patient with a particular
condition than on the specific program or policy attributes of the
setting at which the care is provided.
Therefore, we sought public comment on the following 30 additional
measures, which have been identified as hospital outpatient-appropriate
measures and are under consideration for inclusion in the HOP QDRP
measure set, for CY 2010 or subsequent calendar years:
[[Page 66866]]
------------------------------------------------------------------------
NQF endorsed for
inpatient or
Measure ambulatory Description
setting
------------------------------------------------------------------------
1............ PQRI 2 Endorsed 2006..... Percentage of
Low Density patients aged 18-
Lipoprotein 75 years with
Control in Type 1 diabetes (type 1
or 2 Diabetes or type 2) who
Mellitus. had most recent
LDL-C level in
control (less
than 100 mg/dl).
2............ PQRI 3 Endorsed 2006..... Percentage of
High Blood patients aged 18-
Pressure Control 75 years with
in Type 1 or 2 diabetes (type 1
Diabetes Mellitus. or type 2) who
had most recent
blood pressure
in control (less
than 140/80 mm
Hg).
3............ PQRI 4 2 year Endorsement Percentage of
Screening for until May 8, 2009. patients aged 65
Fall Risk. years and older
who were
screened for
fall risk (2 or
more falls in
the past year or
any fall with
injury in the
past year) at
least once
within 12
months.
4............ PQRI 9 Endorsed 2006..... Percentage of
Antidepressant patients aged 18
Medication During years and older
Acute Phase for diagnosed with
Patient with New new episode of
Episode of Major major depressive
Depression. disorder (MDD)
and documented
as treated with
antidepressant
medication
during the
entire 84-day
(12 week) acute
treatment phase.
5............ PQRI 10 2 year Endorsement Percentage of
Stroke and Stroke until May 8, 2009. patients aged 18
Rehabilitation: years and older
Computed with a diagnosis
Tomography (CT) of ischemic
or Magnetic stroke or
Resonance Imaging transient
(MRI) Reports. ischemic attack
(TIA) or
intracranial
hemorrhage
undergoing CT or
MRI of the brain
within 24 hours
of arrival to
the hospital
whose final
report of the CT
or MRI includes
documentation of
the presence or
absence of each
of the
following:
Hemorrhage and
mass lesion and
acute
infarction.
6............ PQRI 11 2 year Endorsement Percentage of
Stroke and Stroke until May 8, 2009. patients aged 18
Rehabilitation: years and older
Carotid Imaging with a diagnosis
Reports. of ischemic
stroke or
transient
ischemic attack
(TIA) whose
final reports of
the carotid
imaging studies
performed, with
characterization
of internal
carotid stenosis
in the 30-99
percent range,
include
reference to
measurements of
distal internal
carotid diameter
as the
denominator for
stenosis
measurement.
7............ PQRI 24 2 year Endorsement Percentage of
Osteoporosis: until May 8, 2009. patients aged 50
Communication years and older
with the treated for a
Physician hip, spine or
Managing Ongoing distal radial
Care Post fracture with
Fracture. documentation of
communication
with the
physician
managing the
patient's
ongoing care
that a fracture
occurred and
that the patient
was or should be
tested or
treated for
osteoporosis.
8............ PQRI 46 2 year Endorsement Percentage of
Medication until May 8, 2009. patients aged 65
Reconciliation. years and older
discharged from
any inpatient
facility (e.g.,
hospital skilled
nursing
facility, or
rehabilitation
facility) and
seen within 60
days following
discharge in the
office by the
physician
providing on-
going care who
had a
reconciliation
of the discharge
medications with
the current
medication list
in the medical
record
documented.
9............ PQRI 53 Endorsed 2006..... Percentage of
Asthma patients aged 5
Pharmacological to 40 with a
Therapy. diagnosis of
mild, moderate,
or severe
persistent
asthma who were
prescribed
either the
preferred long-
term control
medication
(inhaled
corticosteroid)
or an acceptable
alternative
treatment.
10........... PQRI 58 2 year Endorsement Percentage of
Assessment of until May 8, 2009. patients aged 18
Mental Status for years and older
Community- with a diagnosis
acquired of community-
Pneumonia. acquired
bacterial
pneumonia with
mental status
assessed.
11........... Radiation therapy Endorsed May 9, Radiation therapy
is administered 2007. to the breast
within 1 year of initiated within
diagnosis for 1 year of date
women under age of diagnosis.
70 receiving
breast conserving
surgery for
breast cancer.
12........... Adjuvant Endorsed May 9, Consideration or
chemotherapy is 2007. administration
considered or of chemotherapy
administered initiated within
within 4 months 4 months of date
of surgery to of diagnosis.
patients under
the age of 80
with AJCC III
(lymph node
positive) colon
cancer.
13........... Adjuvant hormonal Endorsed May 9, Cancer--Breast--c
therapy. 2007. onsideration or
administration
of accompanying
hormonal therapy
for treatment of
breast cancer.
14........... Needle biopsy to Endorsed May 9, Patient whose
establish 2007. date of needle
diagnosis of biopsy precedes
cancer precedes the date of
surgical excision/ surgery.
resection.
15........... Osteo-02: 2 year Endorsement Bone and joint
Screening or until May 8, 2009. conditions
Therapy for Women (osteoporosis)--
Aged 65 years and Screening or
Older. therapy for
women aged 65
years and older.
[[Page 66867]]
16........... Osteo-03: 2 year Endorsement Bone and joint
Management until May 8, 2009. conditions
following (osteoporosis)--
fracture. Management
following
fracture.
17........... Osteo-04: 2 year Endorsement Bone and joint
Pharmacologic until May 8, 2009. conditions
Therapy. (osteoporosis)--
Pharmacologic
therapy.
18........... EC-01: 2 year Endorsement Percentage of
Electrocardiogram until May 8, 2009. patients aged 40
(ECG) for years and older
Patients with Non- with an
Traumatic Chest emergency
Pain. department
discharge
diagnosis of
nontraumatic
chest pain who
had an
electrocardiogra
m (ECG).
19........... EC-03: ECG 2 year Endorsement Percentage of
Performed for until May 8, 2009. patients aged 18
Patients with to 60 years with
Syncope. an emergency
department
discharge
diagnosis of
syncope who had
an ECG
performed.
20........... EC-04: Vital Signs 2 year Endorsement Percentage of
Recorded and until May 8, 2009. patients aged 18
Reviewed for years and older
Patients with with a diagnosis
Community- of community-
Acquired acquired
Bacterial bacterial
Pneumonia. pneumonia with
vital signs
recorded and
reviewed.
21........... Eye-01: Primary 2 year Endorsement Primary open
Open Angle until May 8, 2009. angle glaucoma--
Glaucoma--Optic optic nerve
Nerve Evaluation. evaluation.
22........... Eye-02: Age- Recommended for Age-related
Related Macular Endorsement. macular
Degeneration--Ant degeneration--an
ioxidant tioxidant
Supplement supplement
Prescribed/ prescribed/
Recommended. recommended.
23........... Eye-03: Age- 2 year Endorsement Age-related
Related Macular until May 8, 2009. macular
Degeneration--Dil degeneration--di
ated Macular lated macular
Examination. examination.
24........... Eye-07: Diabetic 2 year Endorsement Documentation of
Retinopathy--Docu until May 8, 2009. presence or
mentation of absence of
Presence or macular edema
Absence of and level of
Macular Edema and severity of
Level of Severity retinopathy.
of Retinopathy.
25........... Eye-08: Diabetic 2 year Endorsement Communication
Retinopathy--Comm until May 8, 2009. with the
unication with physician
the Physician managing ongoing
Managing Ongoing diabetes care.
Diabetes Care.
26........... GI-09: Colonoscopy Recommended for Colonoscopy for
for Polyp Endorsement. polyp
Surveillance--Des surveillance--de
cription of Polyp scription of
Characteristics. polyp
characteristics.
27........... GER-02: Advance Recommended for Advance care
Care Plan. Endorsement. plan.
28........... GER-03: Urinary 2 year Endorsement Assessment of
Incontinence--Ass until May 8, 2009. presence or
essment of absence of
Presence or urinary
Absence of incontinence in
Urinary women aged 65
Incontinence in years and older.
Women Aged 65
Years and Older.
29........... GER-04: Urinary 2 year Endorsement Characterization
Incontinence--Cha until May 8, 2009. of urinary
racterization of incontinence in
Urinary women aged 65
Incontinence in years and older.
Women Aged 65
Years and Older.
30........... GER-05: Urinary 2 year Endorsement Plan of care for
Incontinence--Pla until May 8, 2009. urinary
n of Care for incontinence in
Urinary women aged 65
Incontinence in years and older.
Women Aged 65
Years and Older.
------------------------------------------------------------------------
As with the Hemoglobin A1c diabetes intermediate outcome measure
described in XVII.B of this preamble, we included two diabetes
intermediate outcome measures in this list of 30 additional measures--
that is, good control of blood pressure (less than 140/80 mm Hg) and
LDL-C levels (less than 100 mg/dl). We specifically invited comment on
these outcome measures.
We solicited comments on these 30 additional measures for inclusion
in the HOP QDRP for CY 2010 or subsequent calendar years and welcomed
comments on whether any of these additional measures should be included
effective for services furnished on or after January 1, 2008 for the CY
2009 update.
Comment: Several commenters questioned in general the
appropriateness of the proposed measures for hospital outpatient care.
In particular, several commenters stated that the listed additional 30
measures were not suitable for hospital outpatient care in their
present form and that the measures should be refined to be more
specific to the hospital outpatient setting. The commenters viewed the
listed additional 30 measures as more relevant to care provided in
other settings, especially physician-based settings.
Response: We acknowledged in the proposed rule that the listed
additional 30 measures are either in use or were developed for use in
settings other than hospital outpatient (72 FR 42801). As we stated, it
is our intent to develop, where feasible, hospital outpatient measures
that are ``harmonized,'' with measures for assessing comparable
inpatient and ambulatory care, that is, comparable care rendered in
different settings can be evaluated in similar ways. We intend to
expand the set of measures on which hospital outpatient settings must
report data for payment decisions for CY 2010 and subsequent calendar
years.
Comment: Several commenters stated that it was difficult to comment
on the additional 30 measures proposed for future use as it was
difficult to know if any of them would be considered best practice in
the near future, noting the period of endorsement was short for many.
Several commenters stated that any quality measure chosen for public
reporting and pay for performance should be generally accepted as best
practice. One commenter stated that quality measures with longer
``shelf-life'' be used.
Response: We agree with the commenters'' position that any quality
measures chosen for public reporting and pay for performance should be
generally accepted as best practice. We understand that it is more
desirable to utilize quality measures with more longevity. We will take
these comments into consideration when we review additional measures
for possible inclusion in the HOP QDRP measure set.
Comment: Three commenters stated that the requirement to collect
[[Page 66868]]
information that affected hospital payment that was dependent on
physician activity fostered a hostile environment. One commenter
emphasized that there is no financial incentive for physicians to
participate in improving hospital outpatient quality measures. One
commenter stated that creation of this hostile environment affected
larger hospitals to a lesser extent and made recruitment/retention more
difficult for smaller hospitals.
Response: Under section 1833(t)(17) of the Act, as added by section
109(a) of the MIEA-TRHCA, CMS is statutorily required to establish a
hospital outpatient care data reporting program. We will continue to
utilize a consensus process in devising measures applicable to the
hospital outpatient setting. As discussed in this final rule with
comment period, a sampling scheme devised around hospital outpatient
volume will be devised to lessen the burden for smaller hospitals. It
is our intent that quality measure reporting will encourage providers
and clinicians to improve their quality of care.
Comment: One commenter provided strong support for one potential
indicator, ``Radiation therapy is administered within 1 year of
diagnosis for women under age 70 receiving breast conserving surgery
for breast cancer.''
Response: We thank the commenter for supplying information
supporting this quality measure and will consider it in the selection
of future HOP QDRP measures.
Comment: Several commenters stated that in regard to the 30
additional measures listed, given the lack of operational data
collection processes for outpatient hospital data and the associated
costs of collecting quality measure data, CMS should not consider any
additional measures, especially for the first year of reporting.
Response: We acknowledge that there is a burden with collecting
quality measure data. As stated in the proposed rule, we indicated that
we were considering the additional listed 30 measures for CY 2010 or
subsequent calendar year reporting requirements, although we also
solicited comments on whether any of the listed 30 additional measures
should be included in reporting for the CY 2009 payment year. Further,
as discussed elsewhere in this final rule with comment period, we have
reduced the number of required reporting measures for the CY 2009
payment year from the 10 we proposed. However, given the importance of
outpatient hospital quality measure reporting it is our intent to
propose additional measures in the future.
Comment: One commenter expressed concern with the use of PQRI
2 and PQRI 3 as these are outcome measures and as
such should not be used as a basis for determining payment. One
commenter strongly opposed the PQRI 14 measure, stating that a
needle biopsy is not always appropriate. One commenter strongly opposed
the PQRI 18 measure, stating that ordering an ECG is a
judgment call, and that an ECG is not always indicated with non-
traumatic chest pain. Several commenters expressed support for cancer
care related measures.
Response: We thank the commenters for expressing these concerns and
will hold these concerns in consideration of future measure
requirements.
Comment: One commenter strongly supported imaging-related quality
measures.
Response: CMS appreciates this comment and intends to incorporate
imaging measures in the future.
Comment: One commenter stated that the term ``outpatient'' needed
to be more clearly defined and that an approach that narrowed the
population of interest for outpatient care by service as do the five
ED-AMI measures and the surgical day care measures (PQRI 21
and PQRI 22) should be used for other measures.
Response: Although PQRI 21 and PQRI 22 were not
in the list of 30 measures included in the proposed rule, we understand
the commenter's intent and thank the commenter for this suggestion. We
will keep it in mind as we consider future measures.
Comment: Several commenters recommended that the same numbering
system be used in the specifications manuals for both the inpatient and
outpatient data tables and in particular, that CMS use of the same
number for corresponding tables.
Response: We thank the commenters for this suggestion and will look
to aligning the specification manuals for inpatient and outpatient
quality measures to the extent possible.
Comment: Several commenters suggested that osteoporosis measures
(PQRI 24, 39, 40, and 41) be
included in the HOP QDRP; and also asked that data collection for these
measures begin in CY 2008. One commenter stated that CMS should promote
the prevention of fragility fractures by distinguishing DXA testing
from pharmacologic therapy in HOP QDRP measures.
Response: We thank the commenters for support of these measures and
for the suggestions. As noted above, to reduce provider burden and
recognizing the need for further refinement of some of the proposed
measures for the outpatient setting, the number of required measures
has been reduced for CY 2008 quality data reporting efforts. We will
consider these measures for future implementation.
Comment: One commenter stated that with respect to the 30
additional listed measures, populations to be included must be
carefully defined so that any public reporting will compare like
populations, to the extent that outcomes data are reported, risk
adjustment was critical, and that process measures be reasonable.
Response: We thank the commenter for these comments to be used in
consideration of future measures.
After consideration of the public comments received and as noted in
the above responses to those comments, we are not collecting data for
any of the additional 30 listed measures under the HOP QDRP for
purposes of the CY 2009 update.
D. Implementation of the HOP QDRP and Request for Additional Suggested
Measures
In the CY 2008 OPPS/ASC proposed rule, (72 FR 42803), we stated
that for purposes of CY 2009 payments, we would require hospitals to
begin to submit data on the 10 measures that we identified under
section XVII.B. of the proposed rule. We also noted that, while we
would expect to focus on these 10 measures and would consider comments
on them for the CY 2009 payment year, we would also consider the
comments received from the public on the list of 30 additional measures
cited above in developing the final lists of measures for future
payment years.
As described below, procedures for submission of hospital
outpatient quality information will mirror as closely as possible all
procedures for submission of inpatient quality information. The
inpatient procedures are identified on the QualityNet Web site, at
http://www.qualitynet.org. As required by new section 1833(t)(17)(E) of
the Act, we will develop procedures to publicly report the measure
results obtained under the HOP QDRP. Hospitals will have an opportunity
to review the information that is to be made available to the public
prior to its being made public.
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 the incorporation of value-based
purchasing into the OPPS. We seek to encourage care that is both
efficient and of high quality in the hospital outpatient setting. We
plan to work quickly and
[[Page 66869]]
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.
In the CY 2008 OPPS/ASC proposed rule, (72 FR 42803), we welcomed
suggestions of other additional measures and topics relevant to the
hospital outpatient setting for future development of the measure set,
particularly measures from other settings (such as hospital inpatient,
physician office, and emergency care settings) that would contribute to
better coordination and harmonization of high quality patient care.
Comment: Two commenters asked for the consideration of the PQRI
4 Screening for Future Fall Risk outpatient quality measure as
well as the following occupational therapist measures, Patient Co-
Development of Plan of Care, Pain Assessment Prior to Initiation of
Patient Treatment, and Universal Documentation and Verification of
Current Medications in the Medical Record. One commenter suggested
measures for preventive care for future use. Several commenters
suggested the inclusion of administration of anti-platelet therapy for
patients with coronary artery disease. One commenter suggested the
inclusion of measures on venous thromboembolism and care coordination.
One commenter suggested the inclusion of additional medical prophylaxis
safety measures including 2 SCIP measures (SCIP-VTE1, venous
thromboembolism prophylaxis ordered for a surgery patient and SCIP-
VTE2, prophylaxis within 24 hours pre/post surgery). One commenter
suggested the development of additional VTE measures. One commenter
suggested that in addition to quality measures, the hospital component
of the Consumer Assessment of Health Providers and Systems (HCAHPS) has
several questions directed to patients that are applicable to hospital
outpatient care and, thus, could provide useful information about
outpatient quality care.
Response: We thank the commenters for supplying additional,
potential quality measures for consideration in the HOP QDRP measure
set.
Comment: One commenter noted that there is a discrepancy between
the SCIP VTE-1 and PQRI 23 measures and that while these are
not proposed measures under this rule, CMS should review all of its
quality measures to ensure compatibility and lack of conflict. One
commenter suggested aligning the PQRI measures with the outpatient
quality measures.
Response: We thank the commenters for these observations, and we
will continue to strive to ensure compatibility and alignment of
measures across settings.
Comment: Several commenters suggested that any financial
implications related to outpatient quality measure reporting be
deferred.
Response: Under section 1833(t)(17)(A)(i) of the Act, as added by
section 109(a) of the MIEA-TRHCA, the HOP QDRP is established to affect
payments effective beginning in CY 2009.
E. Requirements for HOP QDRP for CY 2009 and Subsequent Calendar Years
In the CY 2008 OPPS/ASC proposed rule, (72 FR 42803), we stated
that in order to participate in the HOP QDRP for CY 2009 and subsequent
calendar years, hospitals must meet administrative, data collection and
submission, and data validation requirements. Hospitals not
participating in the program or that withdraw from the program will not
receive the full OPPS payment rate update. Instead, in accordance with
the law, those hospitals would receive a reduction of 2.0 percentage
points in their updates for the affected payment year.
Hospitals not meeting the requirements of the HOP QDRP also will
not receive the full OPPS payment rate update. Instead, in accordance
with the law, those hospitals also would receive a reduction of 2.0
percentage points in their payment update factor for the affected
payment year.
We proposed the following requirements for participation in the HOP
QDRP:
1. Administrative Requirements
To participate in the HOP QDRP, the hospital must complete several
administrative steps. These steps, as in the current IPPS RHQDAPU
program, require the hospital to:
Identify a QualityNet Exchange administrator who follows
the registration process and submits the information through the CMS-
designated contractor. The same person may be the QualityNet Exchange
administrator for both the IPPS RHQDAPU program and the HOP QDRP. This
designation must be kept current and must be done, regardless of
whether the hospital submits data directly to the CMS designated
contractor or uses a vendor for transmission of data.
Register with the QualityNet Exchange, regardless of the
method used for data submission.
Complete the Notice of Participation form. All hospitals
must send the form to a CMS-designated contractor no later than
November 15, 2007 for the CY 2009 HOP QDRP. At this time, the
participation form for the HOP QDRP is separate from the IPPS RHQDAPU
program and completing a submission form for each program is required.
Agreeing to participate includes acknowledging that the data submitted
to the CMS designated contractor will be submitted to CMS and may be
shared with a CMS contractor or contractors supporting the
implementation of this program.
Hospitals not wishing to participate must submit a nonparticipation
form. Hospitals that have completed a notice of participation form and
subsequently wish to stop participating must submit a withdrawal form.
To reduce the burden on hospitals, once a hospital has indicated
its intent to participate or not participate, we will consider the
hospital to be in that status (either a participant or nonparticipant)
until the hospital indicates a change in status by submitting a notice
of participation or a withdrawal form.
Comment: Several commenters requested delays in implementation in
general, though the November 15, 2007 date for submitting the Notice of
Participation form was not mentioned. One commenter urged that
communication of this requirement be made clearly and frequently so
that all hospitals are aware of the steps they need to take to
participate in the HOP QDRP.
Response: We understand the concerns of these commenters and have
decided to delay the deadline for completing the Notice of
Participation form. The deadline for submission of the Notice of
Participation form will be revised from November 15, 2007 to January
31, 2008. It is our intent that the forms for the inpatient and
outpatient programs will be available on the same Web site. We
understand the difficulties inherent in implementing a new data
collection system and have revised the deadline for completion of the
Notice of Participation form as part of efforts to reduce hospital
burden as discussed further later in this section.
Comment: Several commenters expressed appreciation that CMS was
working to utilize existing processes in implementing data collection
of hospital outpatient quality measures.
Response: We thank the commenters for their support of our efforts.
Comment: One commenter suggested that small or low volume hospitals
be held harmless on the reporting of outpatient hospital quality
measure data
[[Page 66870]]
due to the undue burden of an essentially unfunded mandate.
Response: We acknowledge the commenter's concern regarding burden
on smaller hospitals, but continue to view the importance of quality
measure data from all providers of comparable services. As discussed
throughout this section of the final rule with comment period, in
response to such burden concerns, several aspects of the HOP QDRP have
been revised for the first reporting year.
Comment: One commenter asked that there be a single Notice of
Participation form for reporting inpatient and outpatient hospital
quality measure data.
Response: We agree that it would be preferable to have a single
Notice of Participation form for the inpatient and outpatient hospital
quality measure data reporting programs. However, a single form is not
possible at this time due to separations of the data and administrative
systems for the two programs. We will seek to consolidate processes as
much as possible in the future to ease burdens associated with meeting
the different requirements of these two programs.
We are finalizing the administrative requirements as proposed, with
the modification of changing the deadline for the Notice of
Participation form to January 31, 2008.
2. Data Collection and Submission Requirements
We proposed that, to be eligible for the full OPPS payment update
in CY 2009 and subsequent years, hospitals must:
Collect data required for the finalized set of measures,
beginning with the specifications of the finalized set of measures that
will be identified in the CY 2008 OPPS/ASC final rule (for payment
updates for CY 2009 services) and that will be published and maintained
in a specifications manual to be found on the Web site at: http://www.qualitynet.org.
Submit the data according to a data submission schedule
that will be available on the QualityNet Exchange Web site. We proposed
to have HOP data submitted through the QualityNet Exchange secure Web
site (https://www.qnetexchange.org). This Web site meets or exceeds all
current Health Insurance Portability and Accountability Act
requirements. The submission deadline for January 2008 discharges was
May 31, 2008 with proposed submission deadlines for all other data
submissions being 4 months after the last day of the calendar quarter.
Data would be submitted to the CMS designated contractor using either
the CMS Abstraction and Reporting Tool for Outpatient Department
measures (CART-OPD) or another third-party vendor that has a tool which
has met the measure specification requirements for data transmission to
the QualityNet Exchange.
HOP QDRP data submission will be through the CMS contractor's
secure Web site. Detailed information about the Web site for submitting
quality measure data under the HOP QDRP is not available as of the
publication of this final rule with comment period. We anticipate
awarding the contract to design and manage the OPPS Clinical Warehouse
in the near future. We expect the CMS contractor's Web site to meet or
exceed all current Health Insurance Portability and Accountability Act
requirements for security of personal health information.
The OPPS Clinical Warehouse will submit the data to CMS on behalf
of the hospitals. While the CMS contract for managing the OPPS Clinical
Warehouse was not awarded prior to publishing the proposed rule, we
noted it was possible that a QIO contractor (or subcontractor) would
manage the OPPS Clinical Warehouse. Because the information in the OPPS
Clinical Warehouse also may be considered QIO information, it may be
subject to the stringent QIO confidentiality regulations in 42 CFR part
480.
For purposes of the CY 2009 annual payment update, we proposed to
require hospitals to submit data, for the finalized set of measures,
beginning with services furnished on or after January 1, 2008. The
deadline for submission of data for January 2008 discharges would be 4
months from the last day of the month, May 31, 2008. The deadline for
submission for February-March 2008 discharges would be August 1, 2008.
Thereafter, participating hospitals would be required to submit
quarterly data on finalized measures 4 months from the last day of the
calendar quarter for as long as the hospitals participated in the HOP
QDRP.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42804), we stated our
expectation that hospitals will submit data under the HOP QDRP on
outpatient episodes of care to which the required measures apply. For
the purposes of the HOP QDRP, an outpatient episode of care is defined
as care provided to a patient who has not been admitted as an inpatient
but who is registered on the hospital's medical records as an
outpatient and receives services (rather than supplies alone) directly
from the hospital. Every effort will be made to assure that data
elements common to both inpatient and outpatient settings are defined
consistently (such as ``time of arrival''). However, HOP QDRP quality
data, not quality data required to be submitted for a patient treated
under the IPPS RHQDAPU program, would be submitted under the HOP QDRP.
To be accepted by the CMS designated contractor, submissions would,
at a minimum, need to be accurate, timely, and complete. Data are
considered to have been ``accepted'' by the CMS designated contractor,
for purposes of determining eligibility for the full payment rate
update, only when data are submitted prior to the reporting deadline
and after they have passed all CMS designated contractor edits.
In addition to collecting and submitting data as noted above, we
proposed that, to be eligible for the full OPPS payment update in CY
2009 and subsequent years, hospitals must also:
Submit complete and accurate data. A ``complete''
submission would be determined based on sampling criteria that will be
published and maintained in a specifications manual to be found on the
Web site at http://www.qualitynet.org, and must correspond to both the
aggregate number of cases submitted by a hospital and the number of
Medicare claims it submits for payment.
Submit the aggregate numbers of outpatient episodes of
care which were eligible for submission under the HOP QRDP. These
numbers would indicate the number of outpatient episodes of care in the
universe to which sampling criteria are applied.
New hospitals are expected to begin reporting data as soon as
possible, but no later than beginning with services provided the first
day of the calendar quarter immediately following a hospital's receipt
of its Medicare provider number and the hospital's timely completion of
the administrative requirements for participating in the HOP QDRP.
Comment: Several commenters recommended that CMS adopt some delay
in implementation. The commenters suggested that this delay could be
accomplished by phasing in or reducing the number of measures that
hospitals would be required to collect data and delaying the deadline
for initial data submission. Several commenters viewed some or all of
the additional five non-emergency department measures as an
unnecessary, additional burden, asking for delay or elimination of some
or all of these five measures until a system for collecting and
reporting can be evaluated.
[[Page 66871]]
Response: As noted previously, we have revised the number of
required outpatient hospital measure information by reducing the
required measure set from 10 to 7 measures for initial implementation.
For the reporting of quality measures for HOPD affecting CY 2009
payments, data will be required only for the five ED-AMI measures and
the two perioperative care measures (PQRI 20 Perioperative
Care: Timing of Antibiotic Prophylaxis and PQRI 21
Perioperative Care: Selective of Prophylactic Antibiotic). For reasons
discussed above related to hospital burden and refinement of measures
for the outpatient setting, data collection on PQRI 5 Heart
Failure: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin
Receptor Blocker (ARB) for Left Ventricular Systolic Dysfunction
(LSVD), PQRI 59: Empiric Antibiotic for Community-Acquired
Pneumonia, and PQRI 1: Hemoglobin A1c Poor Control in Type I
or II Diabetes Mellitus will not be required in the initial HOP QDRP
measure set.
With regard to commenters' requests that we delay the deadline for
initial data submission, we agree. Due to the importance of the HOP
QDRP and the need for accurate and timely submission of required data,
we are revising our proposed submission period and deadline. Rather
than requiring initial submission for services furnished on or after
January 1, 2008, we are requiring initial submission for services
furnished on or after April 1, 2008. The data submission deadline for
April to June 2008 discharges is November 1, 2008, 4 months from the
last day of the calendar quarter. As proposed, thereafter,
participating hospitals would be required to submit quarterly data on
finalized measures 4 months from the last day of the calendar quarter
for as long as the hospitals participate in the HOP QDRP. As noted, we
are statutorily required to establish a program under which hospitals
will report data on the quality of hospital outpatient care using
standardized measures of care in order to receive the full annual OPPS
update effective for payments beginning in CY 2009. In balancing the
commenters' concerns and the statutory requirements, we have delayed
the initial data submission as much as we believe is possible while
still meeting statutory deadline. For the subsequent data submissions
for CY 2008 services the submission deadlines will be February 1, 2009
for July to September 2008 services and May 1, 2009 for October to
December 2008 services.
Comment: One commenter asked if the quarterly data submission was
due November 1, 2009, as stated in the proposed rule, or if this date
should be November 1, 2008.
Response: As stated above, the deadline for submitting data for the
initial quarterly data submission of April-June 2008 services will be
November 1, 2008.
Comment: One commenter noted that the OPPS appeared to have 1st of
the month data submission deadlines, whereas, the inpatient measures
have a 15th of the month submission deadline and asked for alignment of
the submission deadlines for both.
Response: We understand that there is an interest in alignment to
reduce confusion and data submission errors. However, the dates were
deliberately chosen and spaced accordingly to avoid issues with
concurrent submission of large amounts of data.
Comment: Due to the large volume of outpatient services potentially
involved for quality measure reporting, several commenters suggested
the use of sampling of cases.
Response: We agree with the idea of sampling of cases for reporting
under the HOP QDRP and it is our intent to devise a methodology for
determining sample size requirements based on hospital volume as is
done for inpatient quality measure reporting.
We are finalizing the proposed data collection and submission
requirements with modifications. The initial submission will be for
services furnished on or after April 1, 2008. The final submission date
for the initial quarterly data for April-June 2008 services is November
1, 2008.
3. HOP QDRP Validation Requirements
In the CY 2008 OPPS/ASC proposed rule, we proposed that data
submitted under this program meet validation requirements. The proposed
validation requirements were similar to the FY 2006 IPPS RHQDAPU
program validation requirement (the initial year validation requirement
was added to the IPPS RHQDAPU program) and included independent re-
abstraction of medical record data elements by a clinical data
abstraction center (CDAC). The CMS contractor would randomly select 5
medical records from all January 2008 discharge cases successfully
submitted to the OPPS Clinical Warehouse. The CDAC would mail requests
to the hospitals to send the selected medical records to the CDAC
within 30 calendar days. The CDAC would independently re-abstract the
medical record data elements. We proposed to provide abstraction
feedback to all hospitals on abstracted data elements.
We also proposed the following chart audit validation requirements
for full CY 2009 payment updates:
Apply to January 2008 discharges only.
Require submission of 5 charts sampled from each hospital.
Establish a passing threshold of 80 percent reliability
reflecting the accuracy of submitted data elements used to calculate
quality measures.
Use an upper bound of 95 percent confidence interval to
measure accuracy.
Incorporate clustering of variability at the chart level
into the confidence interval.
Validation is intended to provide some assurance of the accuracy of
the hospital abstracted data. We have specifically chosen these
validation requirements and thresholds to allow this assurance, provide
sufficient time to fully process validation data, and minimize the
burden on hospitals.
To receive the full OPPS payment rate update in CY 2009, CMS
proposed that the hospital must pass our validation requirement of a
minimum of 80 percent reliability, based upon our chart-audit
validation process, for the January 2008 discharges. The 80-percent
reliability threshold is consistent with the IPPS RHQDAPU program
validation reliability threshold. Based on our previous IPPS RHQDAPU
program experience, we believe that this threshold is reasonable and
attainable by the vast majority of hospitals. Several of the measures
used in the OPPS HOP QDRP are similar in construction to inpatient
measures used in the current IPPS RHQDAPU program. Based on the similar
nature of the inpatient and outpatient measure sets, we believe that
the 80-percent reliability threshold is applicable in the OPPS HOP
QDRP.
We proposed that the data for the first reporting period would be
due to the CMS designated contractor by May 31, 2008. We would use
confidence intervals, as discussed below, to determine if a hospital
has achieved an 80-percent reliability. The use of confidence intervals
would allow us to establish an appropriate range below the 80-percent
reliability threshold that would demonstrate a sufficient level of
reliability to allow the data to still be considered validated. We note
that, for both timing and burden reasons, we proposed to apply the
validation requirements only to January 2008 discharges for purposes of
determining eligibility for the full CY 2009 OPPS payment rate update.
However, hospitals would still be required to submit data for
subsequent time periods.
[[Page 66872]]
We proposed to use January 2008 discharges to estimate the
hospitals' validation score for the CY 2009 validation proposed
requirement. The timeframe for data collection, abstraction, and
validation tasks total about nine to ten months between patient
discharges to completion of validation appeals. We believe that using
later discharges for the CY 2009 annual payment update would adversely
impact CMS' ability to complete these tasks and apply the results to
the CY 2009 annual payment update.
Based on our proposed methodology, the confidence interval would be
slightly wider than is currently utilized for the IPPS RHQDAPU program
due to the smaller sample size. However, given this is the first year
of the HOP QDRP, we believe this would be appropriate. We would
estimate the percent reliability based upon a review of five charts and
then calculate the upper 95 percent confidence limit for that estimate.
If this upper limit is above the required 80 percent reliability
threshold, the hospital data would be considered validated. We proposed
to use the design specific estimate of the variance for the confidence
interval calculation, which, in this case, is a single stage cluster
sample, with unequal cluster sizes. (For reference, see Cochran,
William G. (1977) Sampling Techniques, John Wiley & Sons, New York,
chapter 3, section 3.12.) Each sampled medical record is considered as
a cluster for variance estimation purposes, as documentation and
abstraction errors are believed to be clustered within specific medical
records.
Comment: Many commenters asked that validation not be used in
determining payment decisions; that is, that receipt of full OPPS
payment update be attached only to the submission of quality data,
especially for the first year of the program. Commenters urged that for
the CY 2009 HOP QDRP, data validation should be conducted only as a
learning tool for hospitals.
Response: In response to the many comments received on the
validation requirement, acknowledging this is a new data collection
effort, and consistent with the initial implementation of the IPPS
RHQDAPU program, we have decided not to use the HOP QDRP validation
requirement for purposes of the CY 2009 payment update. Thus, there
will be no validation requirement for April-June 2008 services for the
CY 2009 payment update. However, it is our intent to use validation
requirements for determining the CY 2010 payment update.
Comment: Several commenters addressed the reliability threshold set
for validation. Some commenters suggested that reliability thresholds
should start at lower levels and gradually be raised to 80 percent.
Response: We understand that there may be difficulties with
validation levels due to this being a new data collection effort. As
discussed in this final rule with comment period, validation will not
be required for payment decisions affecting the CY 2009 payment update.
We continue to believe that a reliability threshold of 80 percent for
data validation purposes for future years is appropriate, and we intend
to use it beginning with the CY 2010 payment update.
Comment: Several commenters expressed concern about validating data
from a single month for determining payment. Several commenters stated
that at least 6 months of reporting should be required for any measure
before any data validation is done or any decisions regarding payment
are made.
Response: As noted previously, in response to comments on data
volume for determining payment and validation concerns, for purposes of
the CY 2009 payment update, we will consider data reported for the
second calendar quarter of 2008, April to June 2008 without any
validation requirement. It is our intent to use at least 6 months of
reported data for the HOP QDRP for purposes of the CY 2010 payment
update and for subsequent calendar years. Thus, we intend to begin
validation efforts on data submitted from July-September 2008 services
forward.
We are revising our validation requirements from our proposal and
not requiring validation for purposes of the CY 2009 payment update. We
intend to use validation for purposes of the CY 2010 HOP QDRP,
beginning with July-September 2008 services and for subsequent
services.
In summary, after consideration of the public comments received and
as discussed in the above responses to those comments, we are requiring
hospitals to meet the below outlined administrative, data collection,
and submission requirements under the HOP QDRP for payment
determinations affecting the CY 2009 payment update.
1. Administrative Requirements
Identify a QualityNet Exchange administrator who follows
the registration process and submits the information through the CMS-
designated contractor. The same person may be the QualityNet Exchange
administrator for both the IPPS RHQDAPU program and the HOP QDRP. This
designation must be kept current and must be done, regardless of
whether the hospital submits data directly to the CMS designated
contractor or uses a vendor for transmission of data.
Register with the QualityNet Exchange, regardless of the
method used for data submission.
Complete the Notice of Participation form. All hospitals
must send the form to a CMS-designated contractor no later than January
31, 2008 for the CY 2009 HOP QDRP. At this time, the participation form
for the HOP QDRP is separate from the IPPS RHQDAPU program, and
completing a submission form for each program is required. Agreeing to
participate includes acknowledging that the data submitted to the CMS-
designated contractor will be submitted to CMS and may be shared with a
CMS contractor or contractors supporting the implementation of this
program.
Hospitals not wishing to participate must submit a Notice of
Participation form indicating non-participation in the HOP QDRP.
Hospitals that have completed a notice of participation form and
subsequently wish to stop participating must submit a withdrawal form.
Hospitals not participating in the HOP QDRP program or that withdraw
from the program will not receive the full OPPS payment rate update.
Instead, in accordance with the law, those hospitals would receive a
reduction of 2.0 percentage points in their updates for the affected
payment year.
To reduce the burden on hospitals, once a hospital has indicated
its intent to participate or not participate, we will consider the
hospital to be in that status (either a participant or nonparticipant)
until the hospital indicates a change in status by submitting a notice
of participation or a withdrawal form.
2. Data Collection and Submission Requirements
Collect data required for the finalized set of 7 measures
outlined below, beginning with the specifications of the finalized set
of measures identified in this final rule for payment updates for CY
2009 services and that will be published and maintained in a
specifications manual to be found on the Web site at: http://www.cms.hhs.gov.
Participating hospitals must collect data on the 7 required
measures listed below if they have cases meeting the data collection
specifications. Hospitals will be allowed to sample cases and this
[[Page 66873]]
sampling scheme will be provided in advance of required data
collection.
ED-AMI-1--Aspirin at Arrival.
ED-AMI-2--Median Time to Fibrinolysis.
ED-AMI-3--Fibrinolytic Therapy Received Within 30 Minutes
of Arrival.
ED-AMI-4--Median Time to Electrocardiogram (ECG).
ED-AMI-5--Median Time to Transfer for Primary PCI.
PQRI 20 Perioperative Care: Timing of Antibiotic
Prophylaxis.
PQRI 21 Perioperative Care: Selection of
Prophylactic Antibiotic.
Providers must collect data for the required finalized set of
measures identified in this final rule to receive the full payment
update for CY 2009 OPPS services. The measure specifications will be
published and maintained in a specifications manual to be found on the
CMS Web site at: http://www.cms.hhs.gov.
Submit the data according to a data submission schedule
that will be available on the QualityNet Exchange Web site. HOP data
will be submitted through the QualityNet Exchange secure Web site
(https://www.qnetexchange.org). This Web site meets or exceeds all
current Health Insurance Portability and Accountability Act
requirements. Data for the 7 quality measures finalized in this rule
from services occurring during second calendar quarter of 2008 (April-
June 2008) are to be collected. The submission deadline for April-June
2008 service data will be November 1, 2008. All submission deadlines
will be 4 months after the last day of the calendar quarter. Data must
be submitted to the CMS designated contractor using either the CMS
Abstraction and Reporting Tool for Outpatient Department measures
(CART-OPD) or another third-party vendor that has a tool which has met
the measure specification requirements for data transmission to the
QualityNet Exchange.
Hospitals must submit quality data through the CMS contractor's
secure Web site. Detailed information about the Web site for submitting
quality measure data under the HOP QDRP is not available as of the
publication of this final rule with comment period. We anticipate
awarding the contract to design and manage the OPPS Clinical Warehouse
in the near future. We expect the CMS contractor's Web site to meet or
exceed all current Health Insurance Portability and Accountability Act
requirements for security of personal health information.
The OPPS Clinical Warehouse will submit the data to CMS on behalf
of the hospitals. It is possible that the information in the OPPS
Clinical Warehouse may be considered QIO information. If so, it may be
subject to the stringent QIO confidentiality regulations in 42 CFR part
480.
Hospitals are expected to submit data under the HOP QDRP on
outpatient episodes of care to which the required measures apply. For
the purposes of the HOP QDRP, an outpatient episode of care is defined
as care provided to a patient who has not been admitted as an inpatient
but who is registered on the hospital's medical records as an
outpatient and receives services (rather than supplies alone) directly
from the hospital. Every effort will be made to assure that data
elements common to both inpatient and outpatient settings are defined
consistently (such as ``time of arrival''). However, HOP QDRP quality
data, not quality data required to be submitted for a patient treated
under the IPPS RHQDAPU program, would be submitted under the HOP QDRP.
To be accepted by the CMS designated contractor, submissions must
be, at a minimum, accurate, timely, and complete. Data are considered
to have been ``accepted'' by the CMS designated contractor, for
purposes of determining eligibility for the full payment rate update,
only when data are submitted prior to the reporting deadline and after
they have passed all CMS designated contractor edits.
In addition to collecting and submitting data as noted above, to be
eligible for the full OPPS payment update in CY 2009 and subsequent
years, hospitals must also:
Submit complete and accurate data. A ``complete''
submission is determined based on sampling criteria that will be
published and maintained in a specifications manual to be found on the
Web site at http://www.qualitynet.org, and must correspond to both the
aggregate number of cases submitted by a hospital and the number of
Medicare claims it submits for payment. To be considered ``accurate,''
submissions must pass validation. As stated previously in this section,
we are revising our validation requirement from the proposed rule for
purposes of the CY 2009 payment update. Thus, there is no validation
requirement for the initial reporting period (April to June 2008)
affecting the CY 2009 payment update. It is our intention that there
will be validation requirements under the HOP QDRP as outlined in this
section for reporting periods beginning July-September 2008 services
forward that will be considered for payment decisions beginning with
the CY 2010 payment update.
Submit the aggregate numbers of outpatient episodes of
care which were eligible for submission under the HOP QRDP beginning
with the first reporting period (April-June 2008) forward. These
numbers would indicate the number of outpatient episodes of care in the
universe to which sampling criteria are applied.
New hospitals are expected to begin reporting data as soon as
possible, but no later than beginning with services provided the first
day of the calendar quarter immediately following a hospital's receipt
of its Medicare provider number and the hospital's timely completion of
the administrative requirements for participating in the HOP QDRP.
Hospitals must submit data under the HOP QDRP on outpatient
episodes of care to which the required measures apply. Data submission
deadlines for the submission of this data will be the same as for
submission of quality measure data, will begin with the submission of
April-June 2008 services forward, and will be due 4 months from the
last day of the calendar quarter. For the purposes of the HOP QDRP, an
outpatient episode of care is defined as care provided to a patient who
has not been admitted as an inpatient but who is registered on the
hospital's medical records as an outpatient and receives services
(rather than supplies alone) directly from the hospital.
3. HOP QDRP Validation Requirements
As discussed above, we are not implementing a data validation
requirement for data submitted for the April-June 2008 time period for
the purposes of the CY 2009 annual payment update. It is our intention
that there will be validation requirements as discussed previously and
outlined below for data submitted for July 2008 services forward to
affect payment determinations for CY 2010 and subsequent calendar
years. The validation requirements include independent reabstraction of
medical data elements by a clinical data abstraction center (CDAC). The
CMS contractor will randomly select 5 cases from all cases successfully
submitted to the OPPS Clinical Warehouse for any relevant time period.
The CDAC will mail requests to the hospitals to send the selected
medical records or other supporting documentation to the CDAC within 30
calendar days. The CDAC will independently reabstract the medical
record data elements. Abstraction feedback will be provided to all
hospitals on abstracted data elements.
At this time, the following audit validation requirements are
intended to
[[Page 66874]]
apply for full CY 2010 payment updates forward:
A time period of services after the initial April to June
2008 time period will be determined. At this time, we intend to use
data from July 2008 services forward for the HOP QDRP for the CY 2010
payment update.
Submission of supporting documentation for 5 selected
cases sampled from each hospital is required.
A passing threshold of 80 percent reliability reflecting
the accuracy of submitted data elements is set to calculate quality
measures.
An upper bound of 95 percent confidence interval to
measure accuracy is set.
Clustering of variability at the chart level will be
incorporated into the confidence interval.
To receive the full OPPS payment rate update, the hospital must
pass our validation requirement of a minimum of 80 percent reliability,
based upon our audit validation process, for the designated time
periods.
The methodology to be used for calculating the confidence intervals
under the HOP QDRP is that currently utilized for the IPPS RHQDAPU
program. Due to the small sample sizes during CY 2010 (as noted above,
data from only 5 cases will be used), we anticipate that the calculated
confidence intervals will be larger. However, as CY 2010 is only the
second year of the HOP QDRP, we view this as appropriate. We anticipate
estimating the percent reliability based upon a review of 5
documentation audits and then calculating the upper 95 percent
confidence limit for that estimate. If that upper limit is above the
required 80 percent reliability threshold, we anticipate considering
the hospital's data valid for payment update purposes for CY 2010
forward. As proposed, we intend to use the design specific estimate of
the variance for the confidence interval calculation, which, in this
case, is a single stage cluster sample, with unequal cluster sizes.
(For reference, see Cochran, William G. (1977) Sampling Techniques,
John Wiley & Sons, New York, chapter 3, section 3.12.) Each sampled
medical record is considered as a cluster for variance estimation
purposes, as documentation and abstraction errors are believed to be
clustered within specific medical records.
F. Publication of HOP QDRP Data Collected
New section 1833(t)(17)(E) of the Act requires that the Secretary
establish procedures to make data collected under this program
available to the public and to report the quality measures on the CMS
Web site. Our intent is to make this information public in CY 2009 by
posting it on the CMS Web site. Participating hospitals will be granted
the opportunity to preview this information prior to its public posting
as we have recorded it.
Comment: Several commenters provided thoughts on the publication of
quality data collected. The commenters believed that consumers should
be able to access quality data and cost information electronically that
is organized to allow comparison of information that is correct,
current, and clear. They suggested that the information be presented on
all available sites of service so consumers can compare a hospital
outpatient department with an ASC for a procedure that can be performed
in both settings. They also suggested that there be a provider
narrative section to address information regarding reliability or
accuracy, and provider-specific information such as accreditation
status.
Response: We thank the commenters for their support of providing
public access to hospital outpatient quality data. We strive to present
information contained on Web sites in as complete and clear manner
possible. We also thank the commenters for their thoughts on additional
information that could be included that would aid consumers in
assessing a provider's quality measure data.
After consideration of the public comments received and as
discussed in the above responses to those comments, we intend that
information collected under the HOP QDRP will be made public in CY 2009
by posting it on the CMS Web site. Information from non-validated data,
including the initial reporting period (April-June 2008) will not be
posted. Participating hospitals will be granted the opportunity to
preview this information prior to its public posting as we have
recorded it.
G. Attestation Requirement for Future Payment Years
CMS also solicited comments on whether to implement an HOP QDRP
attestation requirement in CY 2010 and subsequent payment years similar
to the proposed attestation requirement in the IPPS RHQDAPU program set
out in the FY 2008 IPPS proposed rule (72 FR 24808). Hospitals would be
required to submit a written form to a CMS contractor indicating that
they formally attest to the accuracy and completeness of their data,
including the volume of data submitted to the OPPS Data Warehouse. We
anticipated that the attestation form submission deadlines would
parallel the HOP QDRP periodic data submission deadlines.
Comment: One commenter stated that an attestation statement would
be acceptable as long as providers have sufficient time to review and
verify that data were submitted accurately. No comments against the
requirement of an attestation statement were received.
Response: Under any attestation procedure we implement, providers
would have time to review and verify that data were submitted
accurately.
In light of the public comments received we intend that an
attestation procedure similar to the attestation requirement utilized
in the IPPS RHQDAPU program will be included in the HOP QDRP for CY
2010 and subsequent payment years.
H. HOP QDRP Reconsiderations
When the IPPS RHQDAPU program was initially implemented, it did not
include a reconsideration submission process for hospitals.
Subsequently, we received many requests for reconsideration of those
payment decisions, and as a result identified a process by which
participating hospitals would submit requests for reconsideration. We
anticipate similar concerns with the HOP QDRP and, therefore, in the CY
2008 OPPS/ASC proposed rule (72 FR 42805) we proposed to establish a
reconsideration process for the HOP QDRP for those hospitals that fail
to meet the CY 2009 HOP QDRP requirements with the procedural details
of that process posted to the QualityNet Exchange Web site, https://www.qnetexchange.org. In the CY 2008 OPPS/ASC proposed rule (72 FR
42805), we sought public comment specifically on the need for a
structured reconsideration process for CY 2009 and subsequent calendar
years. We also requested comment on what such a process should entail.
For example, such a process, if established, could include--
A limited time, such as 30 days from the public release of
the decision, for requesting a reconsideration;
Specific individuals or functions in a hospital
organization that can request such a reconsideration and that would be
notified of its outcome;
The specific factors that CMS will consider in such a
reconsideration, such as an inability to submit data timely due to CMS
systems failures;
Specific requirements for submitting a reconsideration
request, such as a written request for reconsideration specifically
stating all reasons and factors why the hospital believes it did meet
the HOP QDRP program requirements;
[[Page 66875]]
Suggestions regarding the type of entity that should
conduct the reconsideration process; and
The timeframe, such as 60 days, for CMS to provide its
reconsideration decision to the hospital.
We also requested comments on the reasons for not establishing such
a reconsideration process. We indicated that we planned to establish
procedures that are as similar as possible to those used by the IPPS
RHQDAPU program should we finalize our proposal to implement a
reconsideration process for HOP QDRP.
Comment: While we did not receive any comments opposing a
reconsideration process, two commenters suggested that the
reconsideration process be straightforward, transparent, and timely.
One commenter requested that clear guidance on how to submit appeals be
provided, and that any appeals be expedited. One commenter stated that
it was important to have a reconsideration process in the case of
disputes regarding submitted data. One commenter supported having a
reconsideration process similar to the one used under the inpatient
quality measure reporting program.
Response: We thank the commenters for voicing their support for a
reconsideration process. CMS always strives to implement processes that
are straightforward, transparent, and timely and fully intend to
provide guidance on any reconsideration process used for outpatient
hospital data. It is our intent to model a reconsideration process for
the HOP QDRP similar to the one used under the inpatient quality
measure reporting program.
Comment: Several commenters stated there should be an expeditious
mechanism for corrections or resolution of disagreements about any
information posted for public presentation.
Response: We intend that any process put in place for corrections
or resolution of disagreements about any information posted for public
presentation will be as expeditious as possible.
After consideration of the public comments received and as
discussed in the above responses to those comments, we intend that a
reconsideration process modeled after that for reporting inpatient
quality measures will be included in the HOP QDRP for CY 2009 and
subsequent calendar years.
I. Reporting of ASC Quality Data
As discussed in section XVII.A.2. of this final rule with comment
period, section 109(b) of the MIEA-TRHCA (Pub. L. 109-432) amended
section 1833(i) of the Act by redesignating clause (iv) as clause (v),
adding new section 1833(i)(2)(D)(iv), and adding new section 1833(i)(7)
to the Act. These amendments authorize the Secretary to require ASCs to
submit data on quality measures and to reduce the annual increase in a
year by 2.0 percentage points for ASCs that fail to do so. These
provisions permit, but do not require, the Secretary to require ASCs to
submit such data and to reduce any annual increase for non-compliant
ASCs.
In the CY 2008 OPPS/ASC proposed rule, we did not propose to
introduce quality measures for reporting in ASCs for CY 2008 as we did
for the OPPS as described in sections XVII.B. through H. of the
proposed rule. We believe that promoting high quality care in the ASC
setting through quality reporting is highly desirable and fully in line
with our efforts under other payment systems. However, we also believe
that the transition to the revised ASC payment system in CY 2008 poses
such a significant challenge to ASCs that it would be most appropriate
to allow some experience with the revised payment system before
introducing other new requirements. Implementation of quality reporting
at this time would require systems changes and other accommodations by
ASCs, facilities which do not have prior experience with quality
reporting as hospitals already have for inpatient quality measures, at
a time when they are implementing a significantly revised payment
system. We believe that our CY 2008 proposal to implement quality
reporting for HOPDs prior to establishing quality reporting for ASCs
would allow time for ASCs to adjust to the changes in payment and case-
mix that are anticipated under the revised payment system. We would
also gain experience with quality measurement in the ambulatory setting
in order to identify the most appropriate measures for quality
reporting in ASCs prior to the introduction of the requirement in ASCs.
We intend to implement the provisions of section 109(b) of the MIEA-
TRHCA, Pub. L. 109-432, in a future rulemaking.
Comment: Several commenters agreed with our decisions to delay
implementation of quality measures for ASCs. However, one commenter
urged CMS to implement a quality reporting system for ASCs as soon as
possible as all providers that perform the same services should be held
to the same accountability standards with respect to the quality of the
care the deliver. There were no other comments in disagreement with the
planned delay.
Response: We appreciate these commenters' support for our decision
to delay implementation of collection of ASC quality measure data. We
also recognize the necessity of equal accountability for providers of
the same services and appreciate this reminder.
Comment: Several commenters stated that an administrative claims-
based quality measure reporting system should be implemented for ASCs,
similar to that in place for physician reporting. Commenters suggested
that a claims-based system would reduce the financial and
administrative burden for these smaller facilities that more resemble
physician offices than hospitals, noting that ASCs will continue
submitting Medicare claims using the CMS 1500 form as do physicians at
least through 2008, providing ASCs the ability to report data in the
same manner as physicians. One commenter suggested CMS work with ASC
leaders to develop HCPCS level II G codes that would allow facility-
level quality measures to be reported using an administrative claims-
based approach.
Response: We thank the commenters for their suggestions for our
consideration in implementing a quality measure program for ASCs.
Comment: Several commenters stated that CMS should consider the use
of five ASC measures currently under development if the five were NQF-
endorsed. These five measures focus on patient falls, patient burns,
hospital transfer/admission, wrong site/patient/procedure/implant
situations, and prophylactic antibiotic timing similar to PQRI
20 and 21.
Response: We thank the commenters for supplying this information
for our consideration in developing quality measures for ASCs.
After consideration of the public comments received, and as
discussed in the above responses to those comments, we are finalizing
to our decision to delay implementation of ASC quality measure
reporting. We expect to implement the provisions of section 109(b) of
the MIEA-TRHCA, Pub. L. 109-432, in a future rulemaking.
J. FY 2009 IPPS Quality Measures Under the RHQDAPU Program
As stated in FY 2008 IPPS proposed rule (72 FR 24805), we proposed
to add 1 outcome measure and 4 process measures to the existing 27
measure set to establish a new set of 32 quality measures to be used
under the RHQDAPU program for the FY 2009 IPPS annual payment
determination. We proposed to add the following five measures for the
FY 2009 IPPS annual payment determination:
PNE 30-day mortality measure (Medicare patients)
[[Page 66876]]
SCIP Infection 4: Cardiac Surgery Patients With Controlled
6AM Postoperative Serum Glucose
SCIP Infection 6: Surgery Patients With Appropriate Hair
Removal
SCIP Infection 7: Colorectal Patients With Immediate
Postoperative Normothermia
SCIP Cardiovascular 2: Surgery Patients on a Beta-Blocker
Prior to Arrival Who Received a Beta-blocker During the Perioperative
Period
We stated that we planned to formally adopt these measures a year
in advance in order to provide time for hospitals to prepare for
changes related to the RHQDAPU program. We also stated that we
anticipated that the proposed measures would be endorsed by the NQF.
Finally, we stated that any proposed measure that was not endorsed by
the NQF by the time that we published the FY 2008 IPPS final rule would
not be finalized in that final rule.
At the time we published the FY 2008 IPPS final rule, only the PNE
30-day mortality measure had been endorsed by the NQF. Therefore, we
finalized only that measure as part of the FY 2009 IPPS measure set and
stated that we would further address adding additional measures in the
CY 2008 OPPS final rule (that is, this CY 2008 OPPS/ASC final rule with
comment period) and, if necessary, in the FY 2009 IPPS proposed and
final rules. We also responded to comments we had received on the 5
proposed measures. (72 FR 47348 through 47351)
The NQF has endorsed the following additional process measures that
we proposed to include in the FY 2009 RHQDAPU measure set:
SCIP Infection 4: Cardiac Surgery Patients With Controlled
6AM Postoperative Serum Glucose
SCIP Infection 6: Surgery Patients With Appropriate Hair
Removal
As we stated in the FY 2008 IPPS proposed rule (72 FR 24805), these
measures reflect our continuing commitment to quality improvement in
both clinical care and quality, and they demonstrate our commitment to
include in the RHQDAPU program only those quality measures that reflect
consensus among affected parties and that have been reviewed by a
consensus building process. Because these measures are now endorsed by
the NQF, we are finalizing them for the FY 2009 measure set, bringing
the total number of measures in that measure set to 30.
The measure set to be used for FY 2009 annual payment determination
is as follows:
------------------------------------------------------------------------
Topic Quality measure
------------------------------------------------------------------------
Heart Attack (Acute Myocardial Aspirin at arrival.*
Infarction). 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.*
Fibrinolytic
(thrombolytic) agent received
within 30 minutes of hospital
arrival.**
Primary 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-I) 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 Prophylactic antibiotic
(SCIP) named SIP for discharges received within 1 hour prior to
prior to July 2006 (3Q06). surgical incision.**
Prophylactic antibiotics
discontinued within 24 hours
after surgery end time.**
SCIP-VTE 1: Venous
thromboembolism (VTE)
prophylaxis ordered for surgery
patients.***
SCIP-VTE 2: VTE
prophylaxis within 24 hours pre/
post surgery.***
SCIP-Infection 2:
Prophylactic antibiotic
selection for surgical
patients.***
SCIP-Infection 4:
Cardiac Surgery Patients with
Controlled 6AM Postoperative
Serum Glucose.*****
SCIP-Infection 6:
Surgery Patients with
Appropriate Hair Removal.*****
------------------------------------------------------------------------
Mortality Measures (Medicare Acute Myocardial
patients). Infarction 30-day mortality
Medicare patients.***
Heart Failure 30-day
mortality Medicare patients.***
Pneumonia 30-day
mortality Medicare patients.****
------------------------------------------------------------------------
Patients' Experience of Care......... HCAHPS patient
survey.***
------------------------------------------------------------------------
* Measure included in 10 measure starter set.
** Measure included in 21 measure expanded set.
*** Measure added in CY 2007 OPPS final rule.
**** Measure added in FY 2008 IPPS final rule.
***** Measure added in CY 2008 OPPS final rule.
[[Page 66877]]
We also stated in the FY 2008 final rule that the RHQDAPU
participation requirements for the FY 2009 program would apply to
additional measures we adopt for that year's program (72 FR 47361).
Therefore, hospitals must start submitting data for SCIP Infection
4 and SCIP Infection 6 starting with first quarter calendar year 2008
discharges and subsequent quarters until further notice, and hospitals
must submit their aggregate population and sample size counts for
Medicare and non-Medicare patients. These requirements are consistent
with the requirements for the other 24 AMI, HF, PN, and SCIP process
measures included in the FY 2009 measure set. The complete list of
procedures for participating in the RHQDAPU program for FY 2009 is
provided in the FY 2008 final rule (72 FR 47359-47361).
We plan to propose in the FY 2009 IPPS proposed rule that we will
add these two measures to the current 24 process measures included in
the RHQDAPU chart audit validation requirement starting with first
quarter 2008 calendar year discharges. These validation results would
be included as part of a RHQDAPU FY 2010 chart validation requirement
if they are finalized in the FY 2009 IPPS final rule. We are announcing
our intention to make this proposal to provide hospitals with
sufficient advance notice when abstracting and submitting these
measures to CMS.
Since SCIP Cardiovascular 2 is not currently endorsed by the NQF,
CMS will not adopt this measure as part of the official FY 2009 IPPS
measure set for annual payment determination at this time. In addition,
as stated in the FY 2008 IPPS final rule, CMS is not adopting the SCIP
Infection 7 measure as part of the FY 2009 IPPS measure set for annual
payment determination at this time.
XVIII. Changes Affecting Critical Access Hospitals (CAHs) and Hospital
Conditions of Participation (CoPs)
A. Changes Affecting CAHs
1. Background
CAHs are subject to different participation requirements than are
hospitals. Among other requirements, a CAH must be located in a rural
area (or an area treated as rural) and, under section
1820(c)(2)(B)(i)(I) of the Act and Sec. 485.610(c) of our regulations,
must meet an additional distance-related location requirement. Under
this requirement, a CAH must be located at least 35-miles (or, in the
case of mountainous terrain or in areas with only secondary roads, 15-
miles) from the nearest hospital or other CAH. In addition, CAHs
receive payment for services furnished to Medicare beneficiaries
differently. CAHs receive cost-based payment for 101 percent of their
reasonable costs.
Prior to January 1, 2006, the CAH minimum distance eligibility
requirement was not applicable to entities States had certified as
necessary provider CAHs. Approximately 850 current CAHs have been
designated by their States as necessary providers. The criteria used to
qualify a CAH as a necessary provider were established by each State in
its Medicare Rural Hospital Flexibility Program (MRHFP). The State's
MRHFP rural health care plan contains the necessary assurances that the
plan was developed to further the goals of the statute and regulations
to ensure access to essential health care services for rural residents.
States, in consultation with their hospital associations and Offices of
Rural Health, have defined those CAHs that provide necessary services
to a particular patient community in the event that the facility did
not meet the required 35-mile (or, in the case of mountainous terrain
or in areas with only secondary roads, 15-mile) distance requirement
from the nearest hospital or CAH. Each State's criteria are different,
but the criteria share certain similarities and all define a necessary
provider related to the facility location.
However, section 405(h)(1) of Public Law 108-173 amended section
1820(c)(2)(B)(i)(II) of the Act by adding language that ended States'
authority to certify a CAH as a necessary provider, effective January
1, 2006. In addition, section 405(h)(2) of Public Law 108-173 amended
section 1820(h) of the Act to include a grandfathering provision for
CAHs that were certified as necessary providers prior to January 1,
2006. We incorporated these amendments in Sec. 485.610(c) of our
regulations in the FY 2005 IPPS final rule (69 FR 49220). Because those
regulations did not address the situation where the grandfathered CAH
is no longer the same facility due to relocation, in the FY 2006 IPPS
final rule (70 FR 47490), we amended Sec. 485.610 of our regulations
to add a new Sec. 485.610(d) that addressed the relocation criteria a
necessary provider CAH has to meet to retain its necessary provider
designation.
Additional circumstances concerning CAHs with existing necessary
provider designations have come to our attention that we believe also
need to be addressed. Specifically, we have learned that some CAHs with
grandfathered necessary provider designations are co-located with other
hospitals, which typically are PPS-excluded inpatient psychiatric
facilities or inpatient rehabilitation facilities. We are also aware
that there is interest in the creation or acquisition by CAHs with
necessary provider designation of off-campus facilities that they do
not believe would be subject to CAH location requirements.
For the reasons noted below, in the CY 2008 OPPS/ASC proposed rule
(72 FR 42806), we took a proactive approach by proposing a change in
the regulation to be consistent with our belief that the intent of the
CAH program is to maintain hospital level services in rural communities
while ensuring access to care. We believe that this proposed change to
the regulations will help to maintain the integrity of the MRHFP within
the statutory requirements.
2. Co-location of Necessary Provider CAHs
Some necessary provider CAHs are co-located with other hospitals,
particularly specialty psychiatric and/or rehabilitation hospitals.
Prior to the enactment of section 405(g) of Public Law 108-173, it is
understandable that a State MRHFP might have allowed co-location of a
CAH with a necessary provider designation with the specialized services
of a psychiatric and/or an inpatient rehabilitation hospital. The State
may have believed that beneficiary access to care would be enhanced
through the provision of both CAH and these specialized services at the
same location, and the CAH itself might have had difficulty in
providing such services within its permitted bed limits. However,
section 405 of Public Law 108-173 included several provisions that
permit CAHs themselves to address such access to care issues.
Specifically, section 405(e) of Public Law 108-173 amended sections
1820(c)(2)(B)(iii) and 1820(f) of the Act to increase the permitted
number of CAH inpatient beds from 15 to 25. In addition, section 405(g)
of Public Law 108-173 added section 1820(c)(2)(E) to the Act, which
permits a CAH to operate distinct part inpatient psychiatric and/or
rehabilitation units, each subject to a 10-bed limit that is not
included as part of the CAH's 25-bed limit. Therefore, a CAH can
operate a 45-bed facility addressing a wide range of needs in the rural
community it serves. We believe that CAHs seeking to provide access to
specialized services should avail themselves of the statutory
provisions governing distinct part units in CAHs rather than making
arrangements with
[[Page 66878]]
other hospital providers to share space at the CAH location.
In light of these changes to the statute, we proposed to no longer
allow a necessary provider CAH to enter into co-location arrangements
between CAHs and hospitals, unless such arrangements were in effect
before January 1, 2008, and the type and scope of services offered by
the facility co-located with the necessary provider CAH do not change.
Currently, co-location arrangements seem to involve psychiatric or
rehabilitation hospitals. However, we are concerned that, without this
change, there may be situations where more necessary provider CAHs will
co-locate with PPS hospitals. We also cannot rule out a scenario where
two necessary provider CAHs could co-locate after relocation. We
believe the co location of a necessary provider CAH with another
hospital or necessary provider CAH is not consistent with the CAH
statutory framework that establishes requirements for a CAH to be a
certain minimum distance from other hospitals or CAHs. We believe that
the elimination of States' authority to designate necessary provider
CAHs and the new authority for CAHs to operate psychiatric and
rehabilitation units in addition to their expanded ceiling for
inpatient beds should provide sufficient flexibility for necessary
provider CAHs to operate within the statutory framework without
engaging in additional arrangements.
We also proposed to clarify that, under certain circumstances, a
change of ownership of any of the facilities (either the CAH or the
existing co-located facility) with a co-location arrangement that was
in effect before January 1, 2008, will not be considered to be a new
co-location arrangement. If a change of ownership should occur in a CAH
with a grandfathered co-location arrangement on or after January 1,
2008, the provider agreement will be assigned to the new owner unless
the new owner rejects assignment of the provider agreement.
Grandfathered necessary provider CAH status, including grandfathered
co-location arrangements, would not transfer to a new CAH owner who
does not assume the provider agreement from the previous owner. To
obtain CAH designation, the new provider would have to comply with all
the CAH designation requirements, including the location requirements
relative to other providers, that is, more than a 35-mile drive (or 15
miles in areas of mountainous terrain or secondary roads).
3. CAH Provider-Based Facilities
We have consistently taken the position that the intent of the CAH
program is to keep hospital-level services in rural communities,
thereby ensuring access to care (FY 2006 IPPS final rule (70 FR
47469)). A CAH is permitted to create or acquire an off-campus
location, including a distinct part unit that satisfies the location
criteria for a CAH and operates under the CAH's provider agreement
under the provider-based regulations at 42 CFR 413.65. We note that,
under section 1820(c)(2)(B)(i)(II) of the Act, a CAH does not have to
meet the distance requirements relative to other hospitals or CAHs if
it was certified as a necessary provider by the State prior to January
1, 2006. We stated in the FY 2006 IPPS final rule (70 FR 47472), when
addressing the relocation criteria for a necessary provider CAH, that
the ``necessary provider'' designation is specific to the physical
location(s) of the CAH in existence at the time of the designation. We
believe the necessary provider CAH designation cannot be considered to
extend to any new facilities not in existence when the CAH received its
original necessary provider designation. Accordingly, we believe the
creation of any new location that would cause any part of the CAH to be
situated at a location not in compliance with the distance requirements
at 42 CFR 485.610 would cause the entire CAH to violate the distance
requirements.
Of the approximately 1,300 CAHs, 453 CAHs have health clinics, 81
have psychiatric units, and 20 have rehabilitation units. We do not
know how many of the existing clinics and distinct part units are at
off-site locations. However, we are concerned with CAHs creating or
acquiring off-campus locations, including distinct part psychiatric and
rehabilitation units, that do not comply with the CAH location
requirement relative to other facilities. Therefore, when such off-
campus facilities are created by a CAH with a necessary provider
designation, there is no reason to assume that the distance exemption
given to the CAH should be extended without qualification to any
location for that CAH's off-campus facilities. Accordingly, any CAH
off-campus locations must satisfy the current statutory CAH distance
requirements, without exception, regardless of whether the main
provider CAH is a necessary provider CAH.
Therefore, in the CY 2008 OPPS/ASC proposed rule (72 FR 42807), we
proposed to clarify that if a necessary provider CAH, or a CAH that
does not have a necessary provider designation, operates a provider-
based facility as defined in Sec. 413.65(a)(2), or a psychiatric or
rehabilitation distinct part unit as defined in Sec. 485.647 that was
created or acquired on or after January 1, 2008, it must comply with
the distance requirement of a 35-mile drive to the nearest hospital or
CAH (or 15 miles in the case of mountainous terrain or in areas with
only secondary roads). (In the proposed Sec. 485.610(e)(2), we
inadvertently used the phrase ``after January 1, 2008'' instead of ``on
or after January 1, 2008.'' We have corrected this language in this
final rule with comment period. We also included the words ``off-
campus'' before the words ``provider-based locations'' in the same
regulation to conform to the references in the section for off campus
location.)
4. Termination of Provider Agreement
In the event that a CAH with a necessary provider designation
enters into a co location arrangement on or after January 1, 2008, or
acquires or creates an off-campus facility on or after January 1, 2008,
that does not satisfy the CAH distance requirements in Sec.
485.610(c), we proposed that we would terminate that CAH's provider
agreement, in accordance with the provisions of Sec. 489.53(a)(3). (In
proposed Sec. 485.610(e)(3), we inadvertently used the phrase ``after
January 1, 2008'' instead of ``on or after January 1, 2008.'' We have
corrected this language in this final rule with comment period.) The
necessary provider CAH could avoid termination by converting to a
hospital that is paid under the IPPS, assuming that the facility
satisfies all requirements for participation as a hospital in the
Medicare program under the provisions in 42 CFR Part 482. We also noted
that if the necessary provider CAH corrects the situation that led to
the noncompliance, a termination action will not be triggered. A CAH
that is not a necessary provider CAH could not have a co-location
situation due to the distance requirements it is required to meet at
Sec. 485.610(c).
5. Regulation Changes
In the CY 2008 OPPS/ASC proposed rule (72 FR 42807), we proposed to
amend Sec. 485.610 by adding a new paragraph (e) to address situations
under our proposal relating to off-campus and co-location requirements
for all CAHs (including CAHs with necessary provider designations).
Comment: Several commenters stated that while it is a good policy
to eliminate future co-location
[[Page 66879]]
arrangements between CAHs and acute care hospitals, they do not believe
it is a good policy to eliminate relationships between CAHs and other
hospitals in opening psychiatric or rehabilitation services. They
indicated that such a policy change would only limit access to care
without providing cost savings or improving efficiency. The commenters
stated that co-locating with other providers would lead to cost-
effective high quality delivery of health care services to Medicare
beneficiaries and others who need the services. Another commenter
stated that CMS provided no basis for this proposal in the background
material to the proposed rule.
Response: We disagree with the comment that we did not provide a
basis for the proposed requirements. Additionally, we are not seeking
to eliminate Medicare beneficiary access to inpatient psychiatric and
rehabilitation services specifically, or access to any type of care in
general. As we explained in the preamble to the proposed rule, we
proposed the revisions to Sec. 485.610 in light of recent changes to
the statute. These statutory changes allow for: (1) An increase in the
number of CAH inpatient beds from 15 to 25; and (2) a CAH to operate
distinct part inpatient psychiatric and/or rehabilitation units, each
with a 10-bed limit that is not included as part of the CAH's 25-bed
limit. By allowing a CAH to operate a 45-bed facility, these amendments
to the statute permit CAHs themselves to address the access to care
issues mentioned by the commenters.
These statutory provisions clearly provide an opportunity for the
CAH to directly meet the wide range of needs in the rural community it
serves. However, co-location arrangements between CAHs and hospitals
that were in effect before January 1, 2008 would still be permitted,
provided that there is no change in the type and scope of services
offered by the facility co-located with the necessary provider CAH.
Comment: One commenter expressed complete support for the proposal,
and saw it as a clarification of existing policy. The commenter stated
that a CAH provider-based clinic was built across the street from its
outpatient clinic to increase market share as its population was
dwindling. The commenter stated that CAHs were financed and designed to
serve the needs of the underserved, not to compete in the market
against not-for-profit hospitals that are not subsidized like CAHs. The
commenter also stated that since the regulation is a clarification and
is not new, the existing provider-based clinics should not be
grandfathered.
Another commenter stated that it valued the cost-based financial
support that CMS extends to CAHs. The commenter supported CMS' proposed
rule and viewed the proposed policy changes as a step towards restoring
the ``intended spirit'' of the CAH designation.
Response: We appreciate the commenters' support. However, we
disagree with the comment that existing provider-based clinics should
not be grandfathered. The current regulations did not explicitly
address the issue of necessary provider CAHs from acquiring or creating
off-campus facilities that do not meet the minimum distance
requirements. However, our policy has been that CAHs are required to
meet the distance requirement, including any off-campus facilities. In
light of the statutory change to the designations for necessary
provider CAHs, we believe that it is necessary to grandfather existing
provider-based clinics.
Comment: Numerous commenters requested that rural health clinics
(RHCs) be excluded from the category of provider-based entities that
must comply with the proposed change. Some commenters stated that
operating an RHC is the only way to provide healthcare to the medically
underserved population in their service area. One commenter stated that
if CMS does not exempt RHCs from the proposed policy, CMS should allow
grandfathered CAH/provider-based RHCs to move the location of the RHC
without jeopardizing the CAH status of the parent provider.
Response: To be certified as an RHC, the clinic must be located in
an area designated, either by population or geographic area or
location, as a Medically Underserved Area (MUA) or Health Professional
Shortage Area (HPSA). In addition, State governors are allowed to
designate areas with a shortage of professional health services through
the use of statewide shortage designation plans approved by HRSA's
Bureau of Health Professions. Because RHCs have their own location
requirements and because, unlike other provider-based clinics, a
provider-based RHC is a separate entity which undergoes a separate
certification process and has a unique provider identification number
from the base provider, we believe that our concerns leading to our
provider based proposal do not apply to CAH provider-based RHCs.
Accordingly, in this final rule with comment period, we are excluding
RHCs from the list of provider-based facilities at Sec. 413.65(a)(2)
that must comply with this requirement.
Comment: One commenter stated that for any CAH that is landlocked
against future growth, this proposed change would severely restrict the
CAH's ability to provide the quality services required by the
community. At the very least, the commenter urged that CMS increase the
current on-campus yards from 250 yards to 500 or 750 yards. Another
commenter stated that it is reasonable that CAHs are prohibited from
creating new services that are close to competing organizations, but
believed that limiting all off-campus services to only those in place
by the end of the year, would freeze the CAH into an increasingly out-
of-date delivery modality.
Response: We acknowledge the CAH's constraints of having to locate
a provider-based clinic on its campus. However, this rule will not
restrict a CAH from building or obtaining an off-site provider-based
clinic on or after January 1, 2008. The CAH can have a provider-based
clinic that complies with the provider-based rules in Sec. 413.65. In
addition, the off-site clinic must be located more than a 35-mile (or
15-mile) drive from another CAH or hospital. For example, the CAH could
have a provider-based clinic located 2 miles or 10 miles from the
provider CAH, providing the clinic complies with the distance
requirements and is 35 (or 15) miles away from another CAH or hospital.
The regional offices will evaluate these issues on a case-by-case
basis, consistent with all existing regulations. Also, as discussed
above, because we are now excluding RHCs from these CAH provider-based
requirements, a CAH would have even more flexibility in choosing the
location of its provider-based RHC.
Comment: Several commenters stated that they have started plans
(and, in some cases, construction) for a new provider-based facility
that will not be completed by January 1, 2008. They have requested an
exemption to be able to move forward with their plans that were
initiated prior to the publication of the proposed rule.
Response: We recognize that a number of CAHs have plans underway to
build or acquire provider-based facilities that will not be completed
before January 1, 2008. For those CAHs that demonstrate that they have
begun such planning and/or construction, our regional offices will
evaluate those issues on a case-by-case basis. A demonstration that
construction plans were ``under development'' prior to January 1, 2008
could include supporting documentation such as the drafting of
architectural specifications,
[[Page 66880]]
the letting of bids for construction, the purchase of land and building
supplies, documented efforts to secure financing for construction,
expenditure of funds for construction, and compliance with State
requirements for construction such as zoning requirements, application
for a certificate of need, and architectural review. However, we
recognize that it may not have been feasible for a CAH to have
completed all of these activities noted above as examples prior to
January 1, 2008. Thus, we expect the CMS Regional Offices to consider
all of the factors involved in each CAH's plan and make case by case
determinations of whether a CAH can continue its plans to acquire or
construct an off-campus provider-based clinic. We note that we have
also used the above documentation guidelines in Publication 100-20 for
grandfathered specialty hospitals to determine if construction plans
were ``under development.''
Comment: Many commenters stated that CMS should not adopt the
provisions in the proposed rule because limiting off-site clinics would
impede the provision of health care in their surrounding communities
due to the fact that it could not be provided without cost-based
reimbursements. Also, the commenters suggested that as physicians
cannot be paid competitively without cost-based reimbursement, this
would further compound the difficulties in recruiting healthcare
providers to work in rural areas. Other commenters stated that the only
way to recruit and maintain physicians is for hospitals to offer the
competitive salaries that are afforded through a provider-based
arrangement. A few commenters stated that denying CAHs the opportunity
to invest in physician offices in communities where physicians are
desperately needed will disadvantage the patients living in those
areas. One commenter requested that CMS not adopt the provisions of the
proposed rule and enter into a dialogue with CAHs about an approach
that would allow for the level of community-based access and
collaboration being called for by the Institute of Medicine (IOM), the
National Advisory Committee on Rural Health and Human Services, and
other national bodies.
Response: We do not agree that CMS should not adopt the provisions
in the proposed rule because, in addition to grandfathering the
existing provider-based clinics, CAHs will still be able to provide
needed services in their communities through existing and new provider-
based clinics that meet the distance requirements and through on-campus
facilities. In addition, and perhaps most importantly for those CAHs
concerned about access to primary care services in the communities that
they serve, we have revised our initial proposal in order to permit
CAHs to continue to operate provider-based RHCs. Additionally,
physician offices, owned by CAHs, that are not provider-based (billed
under the CAH's provider number) can continue to be operated by CAHs.
We agree with the IOM and other national bodies that contend that
quality of care in rural areas can be maximized through collaboration.
The IOM report entitled, ``Quality through Collaboration: The Future of
Rural Health'' \1\ states that some of the quality shortcomings in
rural areas stem from the lack of access to ``core health care
services'' such as primary care in the community, emergency medical
services, and hospital care. We believe that CAH provider-based
facilities that are located in the immediate communities of the CAH
will help to ensure that the people in those communities have access to
primary care. Also, CAHs will be able to utilize provider-based RHCs to
provide primary care to Medicare beneficiaries.
---------------------------------------------------------------------------
\1\ Institute of Medicine of the National Academies of Science;
Report released on November 1, 2004.
---------------------------------------------------------------------------
Comment: By providing specific details and scenarios about their
own CAHs, many commenters expressed other reasons for requesting that
CMS not adopt this proposal. Overall, the commenters believed that the
proposed requirements, if implemented, would have the unintended effect
of limiting access to healthcare services for the residents of their
communities. The reasons these commenters gave for requesting that CMS
not adopt the proposal were as follows:
Several commenters stated that the rule would have a
devastating impact on many senior citizens who do not drive and who
would therefore not have access to quality health care in their rural
community. One commenter stated that the proposed change would take
away their organization's opportunity to be cost reimbursed from
Medicare and Medicaid. The commenters stated that this would be a
roadblock to increased access to care for the elderly and low income.
One commenter expressed concern about linking an off-
campus or distinct part unit's compliance to the CAH distance
requirements with the hospital's continued designation as a CAH and
believed that such applications of the distance requirements could
result in decreasing patients' access to surgical and other procedures
that are provided in the CAH. Other commenters were concerned that this
proposed rule would ban necessary provider CAHs from operating an off-
site facility.
One commenter stated that its Medicare designation as a
sole community hospital has geographic limitations, but that it should
not be threatened with loss of its special reimbursement status if it
meets community needs by developing provider-based or off-campus
services. The commenter questioned why CMS is treating CAHs
differently.
Several commenters stated that access will be diminished
in many rural communities because those areas are experiencing an
increasing inability to recruit or retain physicians in non-provider-
based practices due to perceived inadequate Medicare and Medicaid
payment to free-standing RHCs, insufficient payment for physicians
under the fee-schedule, and healthcare professional workforce
shortages. One commenter stated that to continue to apply the
``necessary provider'' designation to off-site services will preserve
one of the only methods that a CAH has to recruit physicians to rural
service areas. The commenter stated that CMS should allow the necessary
provider CAH to have a waiver provision for off-site services beyond
January 1, 2008 if other hospitals within the radius have no objections
to the services.
One commenter stated that the proposed rule indicates CMS'
interest in constraining CAHs. The commenter encouraged CMS to adopt a
philosophy that limits unnecessary constraints and enables CAHs to
serve their patients. The commenter urged CMS to remain supportive of
the CAH program. Additionally, one commenter stated that CMS has
already weighed in on the issues where cost-based reimbursement could
be a major advantage and has eliminated cost-based reimbursement for
certain lab services. The commenter noted that there may be situations
where other services need to be considered, but that they should be
dealt with on a case-by-case basis. If competitive advantage for CAHs
is a concern for CMS, the commenter asked that examples be given of
such arrangements and suggested that a more narrowly tailored rule
should be designed to address such issues.
Several commenters stated that the purpose of the CAH
program is to provide financial stability for small rural hospitals to
serve their communities. The commenters believed that this rule would
eliminate the CAH's ability to provide care to rural seniors. Another
commenter stated that the
[[Page 66881]]
regulation would be devastating to many provider-based clinics because
they would be unable to provide the same level of care, services, and
staffing as independent sites. Several commenters stated that by
forcing CAHs to have services on-campus, CMS will be leaving some
community members without access to services.
Response: We appreciate the varied comments. We first note that the
proposed change will not eliminate the 101 percent reasonable cost
reimbursement that CAHs currently receive. As stated earlier, we do not
believe access to these needed services will be diminished as CAHs will
still be able to increase access to care for the population of its
community through a variety of means. Both the grandfathering provision
of this rule, which allows for provider-based locations and off-campus
distinct part psychiatric and rehabilitation units that were created or
acquired before January 1, 2008, and the exclusion of provider-based
RHCs from the rule provide CAHs with excellent opportunities to not
only maintain access to care but to expand it as well. The role that
RHCs play in providing rural communities with essential access to
primary care services cannot be overemphasized.
From the inception of the CAH program, which started with the
essential access community hospitals and rural primary care hospitals
(EACH/RPCH) 7-State demonstration program, we have been sensitive to
the special needs of, not only the CAH program, but of all rural and
remote providers. This sensitivity has been demonstrated in regulations
we recently adopted that provide flexibility in staffing requirements
and physician oversight of nonphysician practitioners in CAHs.
Ultimately though, the distance-based requirement, as one of the
requirements to become certified as a CAH, is provided for in the
statute and in the regulation. We believe the distance requirement is a
statutory requirement that reflects the intent of the CAH program to
provide hospital-level services in essentially small rural communities.
Our proposal reflects this understanding and the special status of CAHs
(as opposed to other rural entities) and should not limit access to
care. In addition, as the distance requirement is statutory, a waiver
of the distance requirement for some CAHs, as one commenter requested,
would not be allowed under the statute. However, CAHs (including
necessary provider CAHs) will still be able to acquire and create new
provider-based clinics as long as those provider-based clinics are
either RHCs or entities that comply with the distance requirements for
a CAH that are allowed under the Act and under the requirements. In
addition, all CAHs will be able to establish provider-based entities on
their campus.
Comment: One commenter requested that CMS clarify provider-based
location and indicate whether it includes on-campus.
Response: Provider-based status means the relationship between a
main provider and a provider-based entity or a department of a provider
(with all terms being defined in detail under Sec. 413.65(a)(2)).
Provider-based locations can be both on-campus and off-campus. This
rule would not restrict CAHs from having a provider-based entity on
campus.
Comment: One commenter stated that if CMS adopted the proposed
change for CAHs it should apply to all providers, such as RHCs and
Federally qualified health centers (FQHCs).
Response: We appreciate the commenter's opinion regarding treatment
of all rural providers; however, we note that RHCs and FQHCs have
different requirements for participating in the Medicare/Medicaid
programs than those for CAHs. As we noted previously, we are excluding
RHCs from the CAH provider-based requirement in light of the specific
RHC certification requirements.
Comment: One commenter stated that the proposed change would limit
CAH's ability to compete on a level playing field with PPS or other
for-profit providers who have no restrictions on location of
facilities. Another commenter stated that it is cheaper for the CAH or
other hospitals to move offsite the care that does not need high cost
hospital wing space, such as that provided in physical therapy. The
commenters suggested that it would save CMS money on the cost-report to
allow CAHs to open these offsite locations. A few commenters also
stated that offsite locations may be secured much more reasonably to
offer additional services than additional space which may be obtained
through construction of new facilities on campus.
Response: As stated previously, there are statutory requirements
that dictate the location of CAHs. These statutory location
requirements support the original intent of the CAH program, that is,
to ensure and extend access to healthcare services for rural and remote
communities. The program was never intended to encourage competition
between CAHs and PPS hospitals. However, it might be a reasonable
course of action for a CAH to reevaluate whether the CAH program still
meets the needs of the immediate and surrounding communities. If the
community's needs have changed, the facility may want to reconsider
their CAH status and may elect to become a PPS acute care hospital
without the location limitations that are imposed on CAHs and their
provider-based locations.
Comment: A few commenters stated that since all of their CAHs are
necessary provider CAHs, it would be geographically impossible to find
a new off-campus location that would meet the 35-mile requirement and
that this rule should not apply to necessary provider CAHs.
Response: We believe that there are other options for necessary
provider CAHs that cannot meet the mileage requirements. Some examples
that we have previously discussed are on-campus clinics, provider-based
RHCs, or non-provider-based physician offices owned by CAHs.
Comment: One commenter stated that instead of a 35 (or 15)-mile
restriction, a minimum mileage limitation (for example 10 miles) would
be effective without the potential effect of reducing and/or limiting
resources for rural citizens. Additionally, one commenter stated that
it objected to CMS' classification of this new policy as a
``clarification.''
Response: As we have stated previously, the statute, at section
1820(c)(2)(B)(i)(I) of the Act, and the regulation, at 42 CFR Sec.
485.610, both state that the criteria for designation as a CAH is that
it must be located more than a 35-mile drive (or, in the case of
mountainous terrain or in areas with only secondary roads available, a
15-mile drive) from a hospital, or another CAH. We note a provider-
based clinic (other than an RHC) is considered part of the CAH and it
is paid the same as the CAH, that is, 101 percent of reasonable cost.
As stated above, CAHs by statute and regulation must comply with the
distance requirements. As such, we view this rule as a clarification on
the distance requirements of participation for CAHs and their provider-
based locations and off-campus distinct part units in light of the
change in statute concerning necessary provider designations.
Comment: One commenter objected to CMS proposing these changes in
the hospital OPPS proposed rule because they believed that many CAHs
will not evaluate, pay attention to, or read the OPPS proposed rule.
The commenter believed that such proposed changes should be the subject
of a separate proposed rule. They also believe that, as a result of CMS
proposing these changes
[[Page 66882]]
in the OPPS rule, CMS might not have all the information necessary to
finish the rulemaking on the proposed requirements.
Response: On occasion, we have proposed changes to the CAH program
in an OPPS rulemaking. We point out that the subject of the CAH
proposed changes was included in the title of the OPPS rule. In
addition, CMS has announced the proposed changes during its Open Door
Forums. Having received comments from approximately 200 commenters
(including various rural health and hospital associations), we are
confident that we have received sufficient information, through the
public comment process, necessary to complete the rulemaking process.
Comment: One commenter requested clarification on what CMS means in
the termination discussion of the proposed rule and suggested that
clarification was needed to explain how such a process would work in
practice and how a CAH could avoid losing CAH status. In addition the
commenter believed that the threat of closure is an unduly harsh
punishment when payment for an offending facility could be withheld.
Response: Failure to substantially meet one or more conditions of
participation is a cause for termination in the Medicare program, not
closure of the CAH. A CAH with a necessary provider designation that
enters into a co-location arrangement on or after January 1, 2008, or
acquires or creates an off-campus facility on or after January 1, 2008,
that does not satisfy the CAH distance requirements in Sec.
485.610(c), will be placed on a 90-day termination track as outlined in
section 3012 of the State Operations Manual. During this 90-day period,
the CAH will be afforded every opportunity to come back into compliance
and meet all conditions of participation. As we noted in the proposed
rule, if the CAH corrects the situation that led to the non-compliance,
the termination action against the CAH will cease.
Comment: Several commenters asked if current facilities would be
allowed to relocate or be replaced and keep the current relationship
under the grandfather provisions.
Response: We have addressed in greater detail the situation of a
relocated CAH in the FY 2006 IPPS final rule (70 FR 47490). Generally,
we believe that it would be reasonable for a CAH to be able to move its
facility as long as the new facility can meet the relocation
requirements contained under Sec. 485.610(d), which specify the
criteria a necessary provider CAH must satisfy upon relocation in order
to retain its Medicare provider agreement as a CAH. The requirements
permit such CAHs to relocate as long as they remain essentially the
same provider and continue to provide services to the same rural
service area.
Comment: Several commenters requested that we state which types of
entities to which this policy applies.
Response: While we do not provide a complete list of provider-based
entities in this final rule with comment period, we define a provider-
based entity at Sec. 413.65(a)(2). Generally, with the exception of
RHCs, this CAH provider-based rule will apply to an entity that is
provider-based to a CAH that will bill Medicare under its provider
number for services rendered.
After consideration of the public comments received, we are
finalizing the requirements as proposed with the following revisions.
For the reasons noted previously, in Sec. 485.610(e)(2), we have
revised the language of the regulation to exclude RHCs, as defined
under Sec. 405.2401(b), from the list of provider-based facilities
that must comply with this requirement. We revised proposed Sec.
485.610(e)(2) and Sec. 485.610(e)(3) to correct the date references to
``on or after January 1, 2008.'' Finally, we also added the words
``off-campus'' before the words ``provider-based locations'' in Sec.
485.610(e)(2) and Sec. 485.610(e)(3) to conform these references to
the preamble language.
B. Revisions to Hospital CoPs
1. Background
On November 27, 2006, we published a final rule in the Federal
Register entitled ``Medicare and Medicaid Programs; Hospital Conditions
of Participation: Requirements for History and Physical Examinations;
Authentication of Verbal Orders; Securing Medications; and
Postanesthesia Evaluations'' (71 FR 68672). In that final rule (also
frequently referred to as the ``Carve-out rule''), we finalized
changes, which were based on timely public comments submitted on the
proposed rule published in the March 25, 2005 Federal Register (70 FR
15266), to four of the requirements (or conditions of participation
(CoPs)) that hospitals must meet to participate in the Medicare and
Medicaid programs. Specifically, that final rule revised and updated
our CoP requirements for: completion of the history and physical
examination in the Medical staff and the Medical record services CoPs;
authentication of verbal orders in the Nursing services and the Medical
record services CoPs; securing medications in the Pharmaceutical
services CoP; and, completion of the postanesthesia evaluation in the
Anesthesia services CoP. This action was initiated in response to broad
criticism from the medical community that the then-current requirements
governing these areas were burdensome and did not reflect current
practice.
Since this final rule became effective on January 26, 2007, we have
received a great number of comments and questions from providers about
the timeframe requirements (for both the initial medical history and
physical examination and its update) as well as about the
postanesthesia evaluation requirements. In both areas, commenters have
sought clarification on the application of these requirements for
patients undergoing outpatient surgeries and procedures. While the new
requirements contained in the Carve-out rule provide hospitals greater
flexibility in ensuring the quality of inpatient care, the issues
surrounding outpatient care in the hospital setting, particularly with
regard to outpatient surgeries and procedures, are not clear. After
conducting a thorough review of the hospital CoPs and the interpretive
guidelines, we isolated the relevant issues regarding outpatient care
and proposed revisions to the current regulations to address these
concerns.
According to the most recent data, 30 million surgical procedures
are performed each year in the United States with over 60 percent done
as outpatient procedures and another 10 to 15 percent performed on a
same-day admission basis. These figures combined translate to
approximately 21 million surgical procedures performed each year in the
U.S. on patients who are admitted to the hospital on the day of their
procedure. A majority of these patients are also discharged from the
hospital the same day that they are admitted. It is unclear whether
these numbers also include other procedures, such as diagnostic ones,
which also require anesthesia services, and which include all of the
risks to patient safety inherent in such procedures. In either case,
significant numbers of patients undergo surgeries and other procedures
each year as either outpatients or same-day admission patients.
The current requirements for the completion of the medical history
and physical examination are found in the regulations at Sec. 482.22
(Medical staff CoP), Sec. 482.24 (Medical record services CoP), and
Sec. 482.51 (Surgical services CoP). We believe that these
requirements do not adequately address the patient who is admitted for
outpatient or same-day surgery or a procedure requiring anesthesia
services.
[[Page 66883]]
The standards at Sec. 482.22(c), Medical staff bylaws, and Sec.
482.24(c), Content of record, both contain requirements for a medical
history and physical examination, and an update of the medical history
and physical examination documenting any changes in a patient's
condition if the medical history and physical examination was completed
within 30 days before admission, to be completed and documented within
24 hours after admission. Under the Surgical services CoP at Sec.
482.51(b)(1), there is a provision that requires a complete history and
physical workup to be in the chart of every patient prior to surgery.
However, there is currently no requirement for an updated examination
of the patient, including any changes to the patient's condition, to be
completed and documented after admission or registration, and prior to
any surgery or procedure being performed. For patients who are admitted
as inpatients for surgery to be performed in the next day or so, this
does not pose a problem. These inpatients will be followed while in the
hospital with both daily progress and nursing notes made in their
medical record. In addition, as required under the current regulations,
these patients will also have an updated examination for any changes in
their condition within 24 hours after their admission.
As evidenced by the numbers of outpatient and same day admission
inpatient procedures discussed above, procedures that were once done
only on an inpatient basis are now routinely performed in outpatient
settings. Therefore, the patient is not admitted or registered as an
outpatient until the day of the procedure. Often this admission or
registration is just hours before the procedure is performed. In
addition, there are many patients who are admitted as inpatients on the
same day that they are scheduled for more complex procedures, which
will then require postoperative hospital stays. However, for patients
admitted or registered for outpatient procedures as well as for those
patients admitted on the same day as their surgery, there is currently
no mechanism to ensure that these patients are examined for any changes
in their condition prior to undergoing a procedure. Paragraph (b)(1) of
Sec. 482.51 currently requires that every patient have a complete
medical history and physical examination documented in the chart prior
to surgery, except in emergencies. However, the timeframe requirements
for this medical history and physical examination contained under both
Sec. 482.22(c)(5) and Sec. 482.24(c)(2)(i)(A) allow for a medical
history and physical examination that may be as much as 30 days old.
Without a requirement that an updated examination be completed after
admission and prior to surgery or other procedure, any changes in a
patient's condition would most likely be missed by hospital staff.
Failing to identify changes in a patient's condition prior to surgery
may adversely impact not only the procedure but also consequently, and
perhaps more significantly, the outcome of the procedure for the
patient.
In the CY 2008 OPPS/ASC proposed rule (72 FR 42808), we proposed
revisions to Sec. Sec. 482.22, 482.24, and 482.51 that would require
an updated examination, including any changes in a patient's condition,
to be completed and documented for each patient after admission or
registration and prior to surgery or to a procedure requiring
anesthesia services. These revisions would ensure that any changes in
the patient's condition are discovered before a procedure is performed.
With the most up-to-date information regarding a patient's condition
readily available to hospital staff prior to a procedure, the risks to
patient safety should be minimized and a poor outcome for the patient
would be avoided. However, under these proposed requirements, it is not
our intent to include those minor procedures that only require the
administration of local anesthetics, as might be the case for
procedures such as biopsies of skin lesions or suturing of noncomplex
lacerations.
Conversely, the current requirements at Sec. 482.52, Anesthesia
services, still distinguish between inpatients and outpatients with
regard to postanesthesia evaluation, with the requirements for
outpatient evaluation actually being less stringent than those for
inpatients. When the current hospital regulations were originally
written in 1986, these differences in regulatory oversight may have
been entirely appropriate. At that time there were still very clear
differences between inpatient and outpatient procedures, with inpatient
procedures (and the anesthesia services required) considered much more
serious and complex in nature. Since that time, there has been a
gradual blurring of the distinctions between what were previously
termed ``inpatient'' procedures and those that were classified as
``outpatient'' procedures. Procedures that were once done only on an
inpatient basis are now routinely performed in outpatient settings.
While advances in medical technology and surgical technique have
allowed for this shift, the complexity and seriousness of these
procedures still remain as do the risks to patient health and safety.
Along with the increased complexity and types of outpatient procedures
being performed today, come the higher levels of sedation and
anesthesia required for these procedures. Thus, distinctions between
inpatients and outpatients in the requirements for postanesthesia
evaluations are less relevant than ever.
In addition, the current language regarding the completion and
documentation of an evaluation ``within 48 hours after surgery''
assumes that all patients receiving anesthesia services have undergone
surgery. It also assumes that they have not been discharged from the
hospital prior to the end of this 48-hour timeframe and that they are
still available for evaluation. Many patients who have received
anesthesia services (either general anesthesia or monitored anesthesia
care) have undergone diagnostic or therapeutic procedures as opposed to
surgical ones and are discharged within hours after such procedures.
Diagnostic and therapeutic procedures that require anesthesia services
(either general anesthesia or monitored anesthesia care) include
esophagogastroduodenoscopy (EGD), colonoscopy, endoscopic retrograde
cholangiopancreatography (ERCP), and electroconvulsive therapy (ECT).
Furthermore, and as noted above, even those patients who have undergone
inpatient surgical procedures are often discharged well before 48 hours
after surgery.
Therefore, in the CY 2008 OPPS/ASC proposed rule (72 FR 42809), we
proposed revisions to Sec. 482.52(b) that would ensure that all
patients who have received anesthesia services, regardless of inpatient
or outpatient status, have a postanesthesia evaluation completed and
documented by an individual qualified to administer anesthesia before
they are discharged or transferred from the postanesthesia recovery
area.
Finally, in our review of the CoPs, we discovered a cross-reference
under Sec. 482.23, Nursing services, that is no longer valid. We took
the opportunity in the proposed rule to correct this error through a
proposed technical amendment.
2. Provisions of the Final Regulations
a. Timeframes for Completion and Documentation of the Medical History
and Physical Examination
The proposed revisions to Sec. 482.22(c)(5) retained the
requirement that the medical staff bylaws include a requirement that a
medical history and physical examination be completed no
[[Page 66884]]
more than 30 days before or 24 hours after admission for each patient.
We proposed to revise this provision to include the requirement that
the completion and documentation of the medical history and physical
examination (and the updated examination) would also be required prior
to surgery or a procedure requiring anesthesia services.
We also proposed to retain the current provision that the medical
staff bylaws contain a requirement for the completion and documentation
of an updated examination within 24 hours after admission (when the
medical history and physical examination has been completed within 30
days before admission). However, we proposed to delete the language
regarding the placement of the medical history and physical examination
and the updated examination in the medical record within 24 hours after
admission because we believed that the proposed language requiring not
only the completion, but also the documentation, of both the medical
history and physical examination and the updated examination, would
achieve this purpose. In addition, requirements for the physical
placement of the medical history and physical examination and the
updated examination in the patient's medical record are currently, and
more appropriately, contained under the ``Medical record services'' CoP
at Sec. 482.24(c)(2), which we proposed to retain under the proposed
rule.
Further, we proposed to separate the requirements for the medical
history and physical examination and for the updated examination under
two provisions at Sec. 482.22(c)(5)(i) and Sec. 482.22(c)(5)(ii),
respectively. At Sec. 482.22(c)(5)(i), we proposed to retain the
current requirement that the medical history and physical examination
be completed by a physician (as defined in section 1861(r) of the Act),
an oromaxillofacial surgeon, or other qualified individual in
accordance with State law and hospital policy. However, we proposed to
add the words ``and documented'' after ``be completed'' as well as the
word ``licensed'' after ``qualified'' to further clarify this
requirement. In addition, we proposed to revise Sec. 482.22(c)(5)(ii)
to require that the updated examination of the patient must be
completed and documented by the same individuals as proposed above. We
also proposed to add the words ``or registration'' to follow ``after
admission'' to reflect differences in terminology that may exist with
the admission of patients for outpatient procedures. We proposed this
revision here as well as in Sec. 482.24 and Sec. 482.51, where
appropriate.
We proposed to revise the words ``for any changes in the patient's
condition'' to ``including any changes in the patient's condition'' at
both Sec. 482.22(c)(5) and Sec. 482.24(c)(2)(i)(B).
Under Sec. 482.24(c), Content of record, we proposed to revise
both Sec. 482.24(c)(2)(i)(A) and Sec. 482.24(c)(2)(i)(B) by adding
the language ``but prior to surgery or a procedure requiring anesthesia
services'' with regard to both the completion and the documentation of
the medical history and physical examination and the updated
examination.
We proposed to revise the Surgical services CoP at Sec.
482.51(b)(1) by deleting the language regarding medical histories and
physical examinations that have been dictated but which are not yet
recorded in the patient's chart. Our overall intent in the proposed
rule was to require that the most current information regarding a
patient's condition be available to the hospital staff prior to surgery
or a procedure requiring anesthesia services so that risks to patient
safety can be minimized and potential adverse outcomes can be avoided.
We proposed to retain the language regarding the requirement for a
medical history and physical examination prior to surgery, except in
the case of emergencies, and proposed to extend this to a requirement
for an updated examination. We proposed to divide the requirements for
the medical history physical examination and the updated examination
under two separate provisions at Sec. 482.51(b)(1)(i) and Sec.
482.51(b)(1)(ii) in the Surgical services CoP.
b. Requirements for Preanesthesia and Postanesthesia Evaluations
In the CY 2008 OPPS/ASC proposed rule (72 FR 42810), we proposed to
revise the requirement at Sec. 482.52(b)(1), under the ``Delivery of
services'' standard of the ``Anesthesia services'' CoP for a
preanesthesia evaluation to include the language ``or a procedure
requiring anesthesia services.'' We proposed this revision in order to
include the range of procedures that require anesthesia services but
that are not necessarily surgical in nature. We proposed to add this
language under Sec. 482.52(b)(3) for the postanesthesia evaluation
requirement.
Further, we proposed to revise this standard by deleting both the
words ``with respect to inpatients'' at Sec. 482.52(b)(3) and the
entire provision at Sec. 482.52(b)(4), which are the current
requirements for postanesthesia evaluations for patients. We proposed
to revise Sec. 482.52(b)(3) by requiring that the postanesthesia
evaluation be completed and documented before discharge or transfer
from the postanesthesia recovery area. As discussed above, the intent
of this section of the proposed rule was to eliminate the distinctions
currently found in the regulations between inpatients and outpatients
with regard to anesthesia services.
Comment: One commenter supported CMS's efforts to eliminate the
distinctions, currently found in the hospital CoPs, between inpatients
and outpatients with regard to history and physical examinations,
examination updates, and anesthesia evaluations. They noted that the
proposed changes would help to dispel misconceptions regarding
documentation completion and timeframe requirements. Additionally, the
commenter expressed the opinion that such revisions to the CoPs would
not only ensure complete, accurate, and timely documentation, which is
vital for the protection of patients and for the monitoring of the
quality of care provided by clinical staff but would also ensure the
efficient and effective coordination of care by case managers,
discharge planners, and social services staff.
Response: We appreciate the commenter's support of the proposed
changes and agree that the accurate and timely documentation of patient
medical information is an essential component of quality across the
spectrum of patient care.
Comment: One commenter stated that the proposed requirements for an
updated examination of the patient to be completed and documented in
the patient's medical record within 24 hours after admission or
registration but prior to surgery or any procedure requiring anesthesia
services, would be operationally and unnecessarily burdensome on
hospitals. The commenter noted that the requirement would lead to
surgical scheduling inefficiencies, since surgeons would need to stop
procedures so that they could dictate a medical history and physical
examination or an update. The commenter also expressed the opinion that
it was operationally difficult, if not impossible, to ensure that
documentation of a medical history and physical examination or an
update was placed in the patient's medical record prior to the
beginning of surgery. The commenter requested clarification on these
proposed changes, particularly on which provider could complete the
update and whether it would need to be dictated.
[[Page 66885]]
Response: The changes contained in the proposal are a clarification
of the current medical history and physical examination requirements,
which were contained in the Carve-out rule (71 FR 68672) published
November 27, 2006, and which were discussed above. At the time of the
publication of that final rule, we explained in the preamble that if
the patient's medical history and physical examination was completed
before admission to the hospital, the updated examination must be
completed and documented within 24 hours after admission but before a
surgical procedure. This original intention from the Carve-out rule has
been clarified in this final rule with comment period.
Both the medical history and physical examination and the update
can be completed and documented by a physician (as defined in section
1861(r) of the Act), an oromaxillofacial surgeon, or other qualified
licensed individual in accordance with State law and hospital policy.
The individual who completes the update does not have to be the same
individual who did the medical history and physical examination. Both
documents may be handwritten, dictated and transcribed, or completed
electronically. Under these requirements, hospitals have the
flexibility to establish their own policies for the format in which
this essential patient information is documented in the medical record.
Comment: One commenter stated that they were opposed to the removal
of the language in the current CoPs that requires that the medical
history and physical examination be documented and placed ``on the
medical record'' [sic] within 24 hours. The commenter expressed
concerns about physicians who continue to believe that a dictated, but
not yet transcribed, medical history and physical examination is
adequate because it is ``in the system,'' even though it is not yet
physically in the patient's medical record. The commenter stated that
the current JCAHO standards require that the medical history and
physical examination be in the medical record. The commenter believed
that this requirement should be reinforced in the Medicare hospital
CoPs.
Response: As we stated in our discussion of the proposed change, we
believe that the requirements for the physical placement of the medical
history and physical examination, as well as those for its update, are
more appropriately located where they currently are, that is, under the
Medical record services CoP at Sec. 482.24(c)(2), which we will retain
under this rule. Furthermore, we appreciate the commenter's concerns
regarding medical histories and physical examinations that have been
dictated but not yet transcribed, and, thus, are not physically present
in the patient's medical record. Supporting the overall intent of this
rule to require that the most current information regarding a patient's
condition be available to hospital staff prior to surgery or a
procedure requiring anesthesia services, we proposed to delete the
language currently contained under the Surgical services CoP at Sec.
482.51(b)(1) which allows for medical histories and physical
examinations that have been dictated but which are not yet recorded in
the chart. Additionally, the proposed revisions at Sec. Sec. 482.22,
482.24, and 482.51 all require that the medical history and physical
examination (and its update) be completed and documented in the
patient's medical record within 24 hours after admission or
registration but prior to surgery or a procedure requiring anesthesia
services (and except in the case of emergencies as allowed for under
Sec. 482.51(b)(1)). We intend to finalize the proposed requirements
without further revision. We believe that these requirements will
address concerns regarding documentation and will emphasize the
important role that the timely and complete documentation of patient
information plays in reducing patient risk.
Comment: One commenter stated that the term ``anesthesia services''
should be defined in the requirements and that it should include
standard terminology such as moderate sedation, deep sedation, and
general anesthesia. The commenter also asked whether CMS intends to
apply the same requirements regarding medical histories and physical
examinations and postanesthesia evaluations to moderate sedation
administered by a physician or surgeon and to general anesthesia
administered by an anesthesiologist.
Response: We expect hospitals, which furnish anesthesia services,
to follow the current standards of anesthesia care, along with the
accepted definitions of such care, that have been established by
nationally recognized bodies such as the American Society of
Anesthesiologists (ASA) and the American Association of Nurse
Anesthetists (AANA). We also expect that those established guidelines
should be reflected in the hospital's policies and procedures regarding
anesthesia services as appropriate to the scope of services offered.
The requirements for H&Ps and postanesthesia evaluations are not
the same. As previously discussed, a medical history and physical
examination (and its update, if applicable) is required for each
patient admitted or registered to the hospital. This requirement is not
based on whether the patient is undergoing surgery or a procedure
requiring anesthesia services. However, the medical history and
physical examination (and its update) are required prior to surgery or
a procedure requiring anesthesia services, except in the case of
emergencies.
A postanesthesia evaluation would be required after surgery or a
procedure requiring anesthesia services and must be completed and
documented by an individual qualified to administer anesthesia. The
list of individuals who are qualified to administer anesthesia is set
out at Sec. 482.52(a).
Comment: One commenter supported the proposed changes to the
preanesthesia and postanesthesia evaluation requirements and believed
that they reflected current standards of care. The commenter agreed
with CMS' decision to remove the distinctions between inpatients and
outpatients with regard to the postanesthesia evaluation. The commenter
also agreed with the application of the standards to all patients
receiving anesthesia services regardless of whether they were
undergoing surgical or non-surgical procedures.
However, several commenters took exception to the proposed
requirement that the postanesthesia evaluation be completed and
documented before the patient is discharged or transferred from the
postanesthesia recovery area. Several commenters stated that this part
of the provision does not reflect current standards of postanesthesia
care. One commenter noted that its State's regulations allow for the
use of approved medical staff postanesthesia recovery area criteria,
which means that qualified postanesthesia recovery area staff can
discharge patients from the recovery area if they meet certain
standards established by qualified anesthesia practitioners.
Another commenter pointed out that, as proposed, Sec. 482.52(b)(3)
would create a situation where patients who could be safely transferred
to another unit of the hospital or discharged home would be held for
hours in the recovery area. The commenter further stated that
completing the postanesthesia evaluation in the recovery area is simply
too soon to fully capture or address the patient's complete
postanesthesia experience, including any anesthesia-related
complications, which is more effectively done by anesthesia providers
who make follow-up visits or phone
[[Page 66886]]
calls to patients either later that day or the next.
One commenter stressed that it is the surgeon or lead physician who
determines when the patient is ready for discharge or transfer and that
this decision is based on the monitoring and documentation of the
patient by the recovery nurse. This commenter noted that though there
may be some residual effects from anesthesia, this does not mean that
it is inappropriate to discharge or transfer the patient from the
recovery area. This commenter believed that with proper discharge
instructions specific to that patient, a patient may be safely
discharged home to rest following a procedure and that follow-up over
the phone by the anesthesia provider would then complete the
postanesthesia evaluation.
Two commenters also stated that the proposed requirement for the
timing of the postanesthesia evaluation would place an undue burden on
small rural hospitals where there are a limited number of anesthesia
providers. They argued that such constraints would limit access to
surgical services in these communities by significantly slowing down
the number of cases each day. These commenters argued that such
hospitals would have to hire an additional provider to comply with this
requirement without yielding any benefits to patient safety or access
to care.
Response: We appreciate the comments received. After consideration
of the public comments and a further review of the current standards of
anesthesia care, we agree that our proposed changes to the
postanesthesia evaluation requirements may not truly reflect current
and safe anesthesia practice, may in fact impose a burden on hospitals
and anesthesia providers, and, as an unintended consequence, limit some
patients' access to health care services. Therefore, we have revised
the proposed requirements for the postanesthesia evaluation in this
final rule with comment period to better reflect current standards of
care. We are requiring that the postanesthesia evaluation must be
completed and documented by an individual qualified to administer
anesthesia no later than 48 hours after surgery or a procedure
requiring anesthesia services, and that the postanesthesia evaluation
for anesthesia recovery must be completed in accordance with State law
and with hospital policies and procedures that have been approved by
the medical staff and that reflect current standards of anesthesia
care.
Comment: One commenter requested that CMS regularly update the
online Interpretive Guidelines to reflect changes in the hospital CoPs
and that healthcare professionals and their professional associations
be notified by CMS on a timely basis regarding such updates.
Response: This request is outside of the scope of this rule.
However, we will forward this comment to the appropriate component
within CMS responsible for the Interpretive Guidelines.
c. Technical Amendment to Nursing Services CoP
In the CY 2008 OPPS/ASC proposed rule (72 FR 42810), we proposed to
revise the cross-reference to Sec. 405.1910(c) currently found under
the nursing services CoP at Sec. 482.23(b)(1), as this citation has
been changed and is no longer valid. We proposed a technical amendment
to this provision to correct the cross-reference to Sec. 488.54(c).
We did not receive any public comments on this proposed change.
After consideration of the public comments received, we are
finalizing the proposed changes without revision, with the exception of
those under Sec. 482.52(b)(3). We are revising the proposed revision
to require that the postanesthesia evaluation must be completed and
documented by an individual qualified to administer anesthesia no later
than 48 hours after surgery or a procedure requiring anesthesia
services, and that the postanesthesia evaluation for anesthesia
recovery must be in accordance with State law and with hospital
policies and procedures, which have been approved by the medical staff
and which reflect current standards of anesthesia care. As finalized in
this final rule with comment period, these requirements will provide
hospitals greater flexibility while ensuring the quality and safety of
care provided to patients.
XIX. Changes to the FY 2008 Hospital Inpatient Prospective Payment
System (IPPS) Payment Rates
A. Background
On August 1, 2007, we issued a final rule with comment period to
update the hospital inpatient prospective payment system (IPPS) for FY
2008. (This rule was printed in the August 22, 2007 Federal Register at
72 FR 47130 through 48175.) In that final rule with comment period, as
part of the annual update of policies and payment rates under the IPPS,
we adopted a new patient diagnosis classification system, the Medicare
severity diagnosis-related group (MS-DRG) system, to replace the
existing CMS-DRG system, effective October 1, 2007. To maintain budget
neutrality for the transition to the MS-DRG patient classification
system, using the Secretary's authority under section 1886(d)(3)(A)(vi)
of the Act to adjust the standardized amount to eliminate the effect of
changes in coding or classification that do not reflect real change in
case-mix, we also provided for a documentation and coding adjustment to
the IPPS payment rates of -1.2 percent. On September 28, 2007, we
issued a correction notice to the FY 2008 IPPS final rule with comment
period that corrected an inadvertent technical calculation error made
in the FY 2008 IPPS final rule with comment period that affected IPPS
payment rates, factors, and thresholds. (This notice, which we will
refer to as the ``second FY 2008 IPPS correction notice,'' was printed
in the October 10, 2007 Federal Register at 72 FR 57634.)
On September 29, 2007, the TMA, Abstinence Education, and QI
Programs Extension Act of 2007 TMA), Public Law 110-90, was enacted. As
discussed in more detail in section XIX.B. of this final rule, section
7 of Public Law 110-90 included a provision that reduces the -1.2
percent documentation and coding adjustment for the MS-DRG system that
we adopted in the FY 2008 IPPS final rule to -0.6 percent. To comply
with the provision of section 7 of Public Law 110-90, we are revising
certain FY 2008 IPPS payment rate, thresholds, and factors that were
included in the October 10, 2007 correction notice for the FY 2008
final rule with comment period.
In addition, in this final rule, we are making a policy change to
the IPPS that was not part of Public Law 110-90. In the FY 2008 IPPS
final rule, we established a policy of applying the documentation and
coding adjustment to the hospital-specific rates for Medicare-
dependent, small rural hospitals (MDHs) and sole community hospitals
(SCHs) for FY 2008. We have determined that application of the
documentation and coding adjustment to the hospital-specific rates is
not consistent with the plain meaning of section 1886(d)(3)(A)(vi) of
the Act. Therefore, we have decided to change this policy, effective
October 1, 2007, as discussed in section XIX.B.2. of this final rule.
B. Revised IPPS Payment Rates
1. MS-DRG Documentation and Coding Adjustment
As stated earlier, we adopted the new MS-DRG patient classification
system for the IPPS, effective October 1, 2007. The intent of the MS-
DRG system is to better recognize severity of illness in
[[Page 66887]]
Medicare payment rates. Adoption of the MS-DRGs resulted in the
expansion of the number of DRGs from 538 to 745. By increasing the
number of DRGs and more fully taking into account severity of illness
in Medicare payment rates, the MS-DRGs encourage hospitals to improve
their documentation and coding of patient diagnoses. Because of the
incentives that the MS-DRGs provide for improved documentation and
coding of patient diagnoses, we indicated in the FY 2008 IPPS final
rule that we believe the adoption of the MS-DRGs would lead to
increases in aggregate payments due to improved documentation and
coding without a corresponding increase in actual patient severity of
illness. To maintain budget neutrality, using the Secretary's authority
under section 1886(d)(3)(A)(vi) of the Act to adjust the standardized
amount to eliminate the effect of changes in coding or classification
that do not reflect real change in case-mix, we established a
documentation and coding adjustment of -1.2 percent for FY 2008.
Section 7 of Public Law 110-90 included a provision concerning this
documentation and coding adjustment for the MS-DRGs. Specifically,
section 7 of Public Law 110-90 requires the Secretary to apply a
prospective documentation and coding adjustment for discharges during
FY 2008 of -0.6 percent rather than the -1.2 percent adjustment
specified in the FY 2008 IPPS final rule. To comply with the provision
of section 7 of Public Law 110-90, we are changing the IPPS
documentation and coding adjustment for FY 2008 to -0.6 percent and
recalculating the operating standardized amounts, capital standard
Federal payment rates, the outlier threshold, the offset factors that
are applied to the standardized amounts to account for projected
outlier payments, and the thresholds that are used to evaluate
applications for new technology add-on payments for FY 2008. All of
these revised rates, factors, and thresholds are effective October 1,
2007. These revised rates, factors, and thresholds replace those rates,
factors, and thresholds published in the FY 2008 IPPS final rule and in
the second FY 2008 IPPS correction notice. We issued the second FY 2008
IPPS correction notice prior to enactment of Public Law 110-90 and,
consequently, that correction notice did not reflect the change from
the -1.2 percent to the -0.6 percent documentation and coding
adjustment for FY 2008.
The revised standardized amounts are shown in Table 1A, 1B, 1C, and
1D. As expected, the standardized amounts have increased by about 0.6
percent as a result of changes in the documentation and coding
adjustment required under section 7 of Public Law 110-90.
We also have recalculated the outlier threshold based on the
revised standardized amounts. As a result of the change made by section
7 of Public Law 110-90, the revised outlier threshold for FY 2008 is
$22,185. This represents a decrease of $275 from the previously
published FY 2008 outlier threshold. The revised outlier factors are:
0.948983 for operating national; 0.964060 for operating Puerto Rico;
0.952336 for capital national; and 0.959464 for capital Puerto Rico.
In addition, we have recalculated the thresholds that are being
used to evaluate applications for new technology add-on payments for FY
2008 under the IPPS, as shown in Table 10 below. (We note that, for
ease of reference, we have retained the original table numbering from
the FY 2008 IPPS final rule and the second FY 2008 IPPS correction
notice. As a result, table numbering in this section is not sequential
because only certain tables from the FY 2008 IPPS final rule and the
second FY 2008 IPPS correction notice require changes to comply with
the provisions of section 7 of Public Law 110-90.) These thresholds,
which are equal to the geometric mean standardized charges plus the
lesser of 75 percent of the national adjusted operating standardized
payment amount (increased to reflect the differences between costs and
charges) or 75 percent of 1 standard deviation of mean charges by MS-
DRG, were recalculated due to the change in the standardized operating
amount resulting from the change made by section 7 of Public Law 110-
90. Depending on the particular MS-DRG, the revised new technology
thresholds are either the same as, or have increased slightly from, the
previously published amounts.
Both the FY 2008 IPPS final rule and the second FY 2008 IPPS
correction notice included a table entitled ``Comparison of FY 2007
Standardized Amounts to the FY 2008 Single Standardized Amount with
Full Update and Reduced Update.'' We are including an updated version
of that table in this final rule, which reflects the payment rates,
factors, and thresholds that have been revised to comply with section 7
of Public Law 110-90.
We note that section 7 of Public Law 110-90 includes provisions
concerning documentation and coding adjustments to payment rates for
years after FY 2008. We will address those provisions in future years'
rulemaking for the IPPS.
2. Application of the Documentation and Coding Adjustment to the
Hospital-Specific Rates
Under section 1886(d)(5)(D)(i) of the Act, SCHs are paid based on
whichever of the following rates yields the greatest aggregate payment:
the Federal national rate; the updated hospital-specific rate based on
FY 1982 costs per discharge; the updated hospital-specific rate based
on FY 1987 costs per discharge; or the updated hospital-specific rate
based on FY 1996 costs per discharge. Under section 1886(d)(5)(G) of
the Act, MDHs are paid based on the Federal national rate or, if
higher, the Federal national rate plus 75 percent of the difference
between the Federal national rate and the updated hospital-specific
rate based on either the FY 1982, 1987, or 2002 costs per discharge.
When we recalculated the FY 2008 IPPS rates to comply with the
provision of section 7 of Public Law 110-90, we reviewed the policy we
established in the FY 2008 IPPS final rule of applying the document and
coding adjustment to the hospital-specific rates for MDHs and SCHs. In
that final rule, we stated that we believe the hospital-specific rates
for MDHs and SCHs should be subject to the documentation and coding
adjustment that we were applying under section 1886(d)(3)(A)(vi) of the
Act to maintain budget neutrality for the adoption of the MS-DRGs. That
is, as these hospitals use the same DRG system as all other hospitals,
we believe they should be equally subject to the budget neutrality
adjustment that we were applying for adoption of the MS-DRGs to all
other hospitals.
After further review of this issue, we have decided that the
application of the documentation and coding adjustment to the hospital-
specific rates is not consistent with the plain meaning of the statute.
Section 1886(d)(3)(A)(vi) of the Act provides the Secretary with the
authority to adjust ``the average standardized amounts'' so as to
eliminate the effect of changes in coding or classification of
discharges that do not reflect real changes in case-mix. However,
section 1886(d)(3)(A)(vi) of the Act only provides authority to adjust
the average standardized amounts, and does not refer to the hospital-
specific rates. We continue to believe that it would be appropriate to
apply the documentation and coding adjustment to the hospital-specific
rates because we believe that aggregate IPPS payments will increase
after implementation of the MS-DRGs due to incentives to improve coding
and documentation. However, we believe that such an adjustment is not
authorized under
[[Page 66888]]
section 1886(d)(3)(A)(vi) of the Act. As a result, we are establishing
a policy of not applying the documentation and coding adjustment to the
hospital-specific rates for FY 2008. Consequently, the revised DRG
classification and recalibration factor of 0.995743, established in the
October 10, 2007 correction notice for the FY 2008 IPPS final rule,
which corrected the budget neutrality factor established in the FY 2008
IPPS final rule (72 FR 47416 and 47423), will be applied to the
hospital-specific rates of MDHs and SCHs for FY 2008 without
application of a -1.2 percent or a -0.6 percent documentation and
coding adjustment. This policy is effective October 1, 2007, for FY
2008.
Table 1A.--National Adjusted Operating Standardized Amounts; Labor/
Nonlabor
[69.7 Percent Labor Share/30.3 Percent Nonlabor Share if Wage Index
Greater Than 1]
------------------------------------------------------------------------
Full update (3.3 percent) Reduced update (1.3 percent)
------------------------------------------------------------------------
Labor-related Nonlabor-related Labor-related Nonlabor-related
------------------------------------------------------------------------
$3,478.45 $1,512.15 $3,411.10 $1,482.87
------------------------------------------------------------------------
Table 1B.--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
[62 Percent Labor Share/38 Percent Nonlabor Share if Wage Index Less
Than Or Equal to 1]
------------------------------------------------------------------------
Full update (3.3 percent) Reduced update (1.3 percent)
------------------------------------------------------------------------
Labor-related Nonlabor-related Labor-related Nonlabor-related
------------------------------------------------------------------------
$3,094.17 $1,896.43 $3,034.26 $1,859.71
------------------------------------------------------------------------
Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Rates if wage index Rates if wage index less
greater than 1 than or equal to 1
---------------------------------------------------
Labor Nonlabor Labor Nonlabor
----------------------------------------------------------------------------------------------------------------
National.................................................... $3,478.45 $1,512.15 $3,094.17 $1,896.43
Puerto Rico................................................. 1,462.27 896.23 1,384.44 974.06
----------------------------------------------------------------------------------------------------------------
Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
Rate
------------------------------------------------------------------------
National..................................................... $426.14
Puerto Rico.................................................. 201.67
------------------------------------------------------------------------
Table 10.--Geometric Mean Plus the Lesser of .75 of the National
Adjusted Operating Standardized Payment Amount (Increased To Reflect the
Difference Between Costs and Charges) or .75 of One Standard Deviation
of Mean Charges by Medicare Severity-Diagnosis-Related Group (MS DRG)
October 2007 \1\
------------------------------------------------------------------------
Number of Threshold
MS-DRG cases ($)
------------------------------------------------------------------------
1............................................. 652 $345,031
2............................................. 335 178,142
3............................................. 24,400 248,318
4............................................. 21,825 149,288
5............................................. 634 167,763
6............................................. 296 92,366
7............................................. 378 134,606
8............................................. 583 92,357
9............................................. 1,388 97,098
10............................................ 182 73,504
11............................................ 1,297 71,694
12............................................ 1,956 51,613
13............................................ 1,476 37,000
20............................................ 910 138,461
21............................................ 566 108,125
22............................................ 249 74,864
23............................................ 3,564 81,082
24............................................ 2,168 57,415
25............................................ 8,493 77,774
26............................................ 12,059 52,410
27............................................ 14,191 41,344
28............................................ 1,623 74,228
29............................................ 3,089 45,957
30............................................ 3,592 30,059
31............................................ 1,061 60,385
32............................................ 3,064 35,538
33............................................ 4,237 28,788
34............................................ 821 58,431
35............................................ 2,911 41,625
36............................................ 7,454 36,602
37............................................ 4,803 51,825
38............................................ 16,531 32,848
39............................................ 53,619 23,940
40............................................ 4,585 57,599
41............................................ 8,005 39,541
42............................................ 5,216 34,291
52............................................ 1,188 29,379
53............................................ 590 21,941
54............................................ 4,750 30,273
55............................................ 16,945 24,952
56............................................ 7,800 28,358
57............................................ 48,665 18,154
58............................................ 796 28,750
59............................................ 2,676 21,475
60............................................ 4,240 16,415
61............................................ 1,368 53,087
62............................................ 2,320 42,059
63............................................ 1,150 36,344
[[Page 66889]]
64............................................ 56,448 33,903
65............................................ 115,423 26,274
66............................................ 91,644 19,975
67............................................ 1,403 30,850
68............................................ 12,512 21,801
69............................................ 104,325 17,613
70............................................ 7,165 33,429
71............................................ 10,283 26,043
72............................................ 5,811 19,097
73............................................ 8,728 27,072
74............................................ 32,760 19,857
75............................................ 1,229 34,005
76............................................ 861 22,530
77............................................ 1,112 33,155
78............................................ 1,386 23,660
79............................................ 896 18,688
80............................................ 2,095 24,178
81............................................ 8,250 15,979
82............................................ 1,664 34,288
83............................................ 2,070 28,476
84............................................ 2,527 21,042
85............................................ 5,383 34,836
86............................................ 10,921 26,197
87............................................ 11,827 18,483
88............................................ 730 30,589
89............................................ 2,836 22,350
90............................................ 3,285 16,402
91............................................ 6,763 29,413
92............................................ 15,467 20,636
93............................................ 15,043 15,988
94............................................ 1,533 55,314
95............................................ 1,101 41,950
96............................................ 749 35,573
97............................................ 1,266 50,432
98............................................ 1,065 35,836
99............................................ 637 30,059
100........................................... 16,012 28,517
101........................................... 57,312 17,754
102........................................... 1,373 24,528
103........................................... 15,199 15,977
113........................................... 592 31,418
114........................................... 593 19,667
115........................................... 1,110 25,665
116........................................... 715 23,533
117........................................... 1,406 15,540
121........................................... 609 21,777
122........................................... 666 12,422
123........................................... 2,865 17,881
124........................................... 684 24,261
125........................................... 4,742 15,308
129........................................... 1,401 38,113
130........................................... 1,063 27,826
131........................................... 895 36,667
132........................................... 910 26,200
133........................................... 2,057 31,674
134........................................... 3,781 19,478
135........................................... 430 34,472
136........................................... 503 21,916
137........................................... 847 27,054
138........................................... 926 17,071
139........................................... 1,710 19,625
146........................................... 696 35,254
147........................................... 1,457 25,264
148........................................... 924 17,390
149........................................... 39,487 14,828
150........................................... 945 25,286
151........................................... 6,840 12,717
152........................................... 2,363 22,142
153........................................... 16,167 14,126
154........................................... 1,857 28,071
155........................................... 4,431 20,298
156........................................... 4,969 14,819
157........................................... 1,164 28,432
158........................................... 3,158 19,955
159........................................... 2,365 14,144
163........................................... 13,502 78,360
164........................................... 18,484 48,016
165........................................... 14,267 37,961
166........................................... 20,398 57,329
167........................................... 21,074 39,878
168........................................... 5,555 30,256
175........................................... 12,032 33,180
176........................................... 40,330 25,127
177........................................... 57,526 35,918
178........................................... 72,497 29,908
179........................................... 26,495 23,293
180........................................... 22,628 33,071
181........................................... 32,425 26,996
182........................................... 6,085 21,762
183........................................... 1,679 29,948
184........................................... 4,279 21,041
185........................................... 2,607 14,730
186........................................... 8,586 31,572
187........................................... 10,362 25,688
188........................................... 4,840 19,425
189........................................... 105,009 28,936
190........................................... 57,361 27,734
191........................................... 126,608 22,656
192........................................... 193,798 17,011
193........................................... 88,637 29,505
194........................................... 274,002 23,196
195........................................... 142,476 16,909
196........................................... 5,173 30,869
197........................................... 7,087 25,433
198........................................... 4,822 19,617
199........................................... 3,279 33,401
200........................................... 8,321 23,384
201........................................... 3,470 16,338
202........................................... 32,849 19,060
203........................................... 40,990 13,891
204........................................... 26,244 16,200
205........................................... 5,816 26,248
206........................................... 22,615 17,512
207........................................... 46,394 81,181
208........................................... 79,797 41,263
215........................................... 154 151,824
216........................................... 8,437 161,730
217........................................... 7,940 116,752
218........................................... 2,963 97,926
219........................................... 10,112 131,361
220........................................... 14,302 93,832
221........................................... 7,644 81,272
222........................................... 2,862 150,295
223........................................... 5,774 116,655
224........................................... 1,930 138,362
225........................................... 5,882 109,348
226........................................... 7,078 112,911
227........................................... 50,687 88,751
228........................................... 3,099 124,543
229........................................... 4,351 88,368
230........................................... 1,797 72,722
231........................................... 1,484 138,797
232........................................... 1,799 107,899
233........................................... 16,996 118,324
234........................................... 39,349 86,766
235........................................... 9,680 95,767
236........................................... 33,005 68,343
237........................................... 22,981 84,187
238........................................... 43,967 53,516
239........................................... 13,900 59,293
240........................................... 13,862 40,658
241........................................... 2,927 30,323
242........................................... 17,243 63,797
243........................................... 40,609 50,067
244........................................... 65,831 42,281
245........................................... 6,081 54,243
246........................................... 41,300 65,115
247........................................... 272,543 46,643
248........................................... 5,558 58,161
249........................................... 29,332 41,991
250........................................... 5,768 53,663
251........................................... 39,992 38,522
252........................................... 44,846 48,444
253........................................... 52,457 42,864
254........................................... 53,894 34,709
255........................................... 2,624 38,540
256........................................... 3,944 29,847
257........................................... 694 21,430
258........................................... 599 50,000
259........................................... 7,342 35,334
260........................................... 872 47,409
261........................................... 2,921 28,499
262........................................... 3,284 21,635
263........................................... 792 29,116
264........................................... 30,336 39,332
280........................................... 61,020 35,621
281........................................... 62,050 27,981
282........................................... 57,249 21,202
283........................................... 16,022 31,225
284........................................... 5,089 23,429
285........................................... 3,008 16,066
286........................................... 23,379 40,375
287........................................... 173,151 27,701
288........................................... 3,262 48,462
289........................................... 1,471 35,223
290........................................... 447 27,620
291........................................... 184,689 29,043
[[Page 66890]]
292........................................... 245,075 22,187
293........................................... 200,858 16,283
294........................................... 1,756 20,506
295........................................... 1,631 12,987
296........................................... 1,844 26,712
297........................................... 893 18,216
298........................................... 518 11,608
299........................................... 17,570 27,717
300........................................... 49,533 20,057
301........................................... 37,733 14,452
302........................................... 7,919 23,176
303........................................... 81,896 14,065
304........................................... 2,116 24,314
305........................................... 36,019 13,919
306........................................... 1,385 27,686
307........................................... 6,479 17,568
308........................................... 33,741 27,391
309........................................... 85,320 19,164
310........................................... 156,223 13,820
311........................................... 25,143 12,408
312........................................... 170,267 16,986
313........................................... 222,163 13,782
314........................................... 60,587 30,529
315........................................... 33,354 22,371
316........................................... 18,077 15,239
326........................................... 11,616 86,300
327........................................... 11,348 49,623
328........................................... 8,994 31,842
329........................................... 48,381 78,446
330........................................... 68,497 46,925
331........................................... 29,611 34,940
332........................................... 1,897 72,565
333........................................... 6,490 45,834
334........................................... 3,751 34,051
335........................................... 7,194 67,395
336........................................... 12,815 43,093
337........................................... 8,636 32,710
338........................................... 1,513 58,176
339........................................... 3,289 39,849
340........................................... 3,551 29,763
341........................................... 878 43,074
342........................................... 2,662 32,095
343........................................... 6,796 22,560
344........................................... 897 51,758
345........................................... 3,090 33,808
346........................................... 2,758 25,650
347........................................... 1,577 36,724
348........................................... 4,295 27,903
349........................................... 5,539 17,498
350........................................... 1,802 41,307
351........................................... 4,663 28,433
352........................................... 8,835 18,578
353........................................... 3,076 44,840
354........................................... 9,041 30,936
355........................................... 16,621 21,562
356........................................... 8,411 57,588
357........................................... 8,336 39,793
358........................................... 2,477 30,966
368........................................... 3,069 31,708
369........................................... 4,850 24,300
370........................................... 3,104 18,383
371........................................... 16,940 32,006
372........................................... 23,722 26,630
373........................................... 14,227 19,299
374........................................... 9,505 34,394
375........................................... 20,165 26,552
376........................................... 4,486 20,960
377........................................... 50,797 30,805
378........................................... 118,928 22,456
379........................................... 95,521 17,322
380........................................... 2,934 32,459
381........................................... 5,702 25,732
382........................................... 4,681 18,936
383........................................... 1,307 28,384
384........................................... 8,723 19,941
385........................................... 2,119 33,612
386........................................... 7,449 24,853
387........................................... 5,105 19,162
388........................................... 18,375 29,468
389........................................... 47,827 21,609
390........................................... 47,010 15,176
391........................................... 47,836 25,010
392........................................... 308,502 16,603
393........................................... 24,053 29,116
394........................................... 48,058 22,377
395........................................... 24,695 16,159
405........................................... 3,949 82,266
406........................................... 5,420 49,216
407........................................... 2,195 36,325
408........................................... 1,682 68,612
409........................................... 1,771 46,946
410........................................... 693 35,927
411........................................... 985 65,669
412........................................... 1,098 47,894
413........................................... 850 37,530
414........................................... 5,643 59,314
415........................................... 7,154 40,716
416........................................... 6,018 30,467
417........................................... 16,735 46,569
418........................................... 28,654 36,593
419........................................... 37,427 27,109
420........................................... 738 62,636
421........................................... 1,118 37,131
422........................................... 359 28,797
423........................................... 1,528 64,794
424........................................... 934 44,801
425........................................... 148 35,332
432........................................... 16,397 30,728
433........................................... 9,146 21,794
434........................................... 931 15,756
435........................................... 12,004 32,834
436........................................... 14,157 26,609
437........................................... 4,304 23,809
438........................................... 14,497 31,835
439........................................... 25,932 25,153
440........................................... 26,506 17,450
441........................................... 14,036 29,059
442........................................... 13,192 22,508
443........................................... 6,445 16,775
444........................................... 12,529 31,163
445........................................... 17,390 25,361
446........................................... 16,434 18,758
453........................................... 852 162,946
454........................................... 1,700 108,994
455........................................... 1,715 84,036
456........................................... 770 132,720
457........................................... 2,084 93,391
458........................................... 1,282 76,799
459........................................... 3,212 91,603
460........................................... 51,227 61,623
461........................................... 1,071 78,604
462........................................... 14,292 59,135
463........................................... 5,317 58,718
464........................................... 6,589 40,875
465........................................... 2,748 30,484
466........................................... 3,914 70,332
467........................................... 14,340 53,276
468........................................... 21,479 45,819
469........................................... 29,879 56,126
470........................................... 412,628 41,706
471........................................... 2,241 71,743
472........................................... 6,629 48,496
473........................................... 22,659 39,769
474........................................... 2,857 47,857
475........................................... 3,709 34,489
476........................................... 1,560 23,529
477........................................... 2,262 56,532
478........................................... 7,379 41,594
479........................................... 10,118 33,437
480........................................... 25,993 50,104
481........................................... 74,669 37,466
482........................................... 49,780 31,682
483........................................... 6,572 44,289
484........................................... 17,287 37,116
485........................................... 1,152 55,664
486........................................... 2,066 41,511
487........................................... 1,345 33,504
488........................................... 2,541 33,357
489........................................... 6,198 25,879
490........................................... 21,668 34,253
491........................................... 57,424 22,157
492........................................... 4,761 47,754
493........................................... 16,833 36,159
494........................................... 29,419 27,047
495........................................... 1,888 49,306
496........................................... 5,499 34,296
497........................................... 7,196 26,140
498........................................... 1,258 36,549
499........................................... 1,173 20,709
500........................................... 1,359 47,311
501........................................... 3,956 30,725
502........................................... 6,635 21,338
503........................................... 743 38,573
504........................................... 2,274 30,902
505........................................... 3,142 22,627
506........................................... 921 23,455
507........................................... 840 33,200
[[Page 66891]]
508........................................... 2,717 24,377
509........................................... 674 24,413
510........................................... 994 38,968
511........................................... 4,183 30,425
512........................................... 12,088 21,576
513........................................... 1,104 28,511
514........................................... 1,175 18,054
515........................................... 3,601 50,850
516........................................... 11,512 37,284
517........................................... 17,926 30,578
533........................................... 835 26,707
534........................................... 3,647 14,482
535........................................... 6,888 26,510
536........................................... 34,492 14,330
537........................................... 694 19,017
538........................................... 1,139 12,077
539........................................... 3,397 33,275
540........................................... 4,317 26,909
541........................................... 1,787 20,216
542........................................... 6,196 32,603
543........................................... 18,834 24,660
544........................................... 12,389 16,758
545........................................... 4,061 33,895
546........................................... 6,159 23,684
547........................................... 4,717 16,961
548........................................... 592 32,830
549........................................... 1,139 25,116
550........................................... 855 16,440
551........................................... 9,580 29,166
552........................................... 88,568 17,262
553........................................... 2,820 24,459
554........................................... 20,429 13,865
555........................................... 2,006 21,701
556........................................... 19,316 13,456
557........................................... 3,196 28,928
558........................................... 14,252 17,984
559........................................... 1,646 27,945
560........................................... 4,208 19,203
561........................................... 7,439 12,631
562........................................... 5,051 26,500
563........................................... 36,361 14,373
564........................................... 1,622 27,272
565........................................... 3,385 19,726
566........................................... 2,673 14,394
573........................................... 5,721 44,240
574........................................... 12,468 32,357
575........................................... 6,221 24,293
576........................................... 563 45,021
577........................................... 2,305 31,260
578........................................... 3,228 21,726
579........................................... 3,359 42,843
580........................................... 11,019 29,022
581........................................... 12,249 19,890
582........................................... 5,787 22,538
583........................................... 9,356 17,024
584........................................... 801 29,827
585........................................... 1,687 19,824
592........................................... 4,026 29,402
593........................................... 13,080 21,992
594........................................... 2,828 15,050
595........................................... 1,092 29,735
596........................................... 5,792 18,108
597........................................... 555 29,944
598........................................... 1,502 23,666
599........................................... 342 14,643
600........................................... 611 21,165
601........................................... 841 13,706
602........................................... 21,456 26,755
603........................................... 132,037 16,799
604........................................... 2,652 25,338
605........................................... 22,943 15,043
606........................................... 1,371 23,134
607........................................... 7,242 13,623
614........................................... 1,429 44,434
615........................................... 1,594 32,741
616........................................... 1,145 57,824
617........................................... 6,944 36,311
618........................................... 268 26,622
619........................................... 675 60,418
620........................................... 2,007 41,247
621........................................... 6,560 35,467
622........................................... 1,241 43,164
623........................................... 3,392 32,438
624........................................... 392 23,639
625........................................... 1,107 40,382
626........................................... 2,751 27,124
627........................................... 14,146 17,672
628........................................... 3,297 50,999
629........................................... 4,125 39,920
630........................................... 551 30,418
637........................................... 16,431 26,770
638........................................... 46,657 17,852
639........................................... 36,178 12,405
640........................................... 56,149 24,007
641........................................... 189,293 15,306
642........................................... 1,570 23,279
643........................................... 5,072 30,747
644........................................... 12,220 23,221
645........................................... 8,140 17,134
652........................................... 10,695 57,657
653........................................... 1,591 83,632
654........................................... 3,387 53,616
655........................................... 1,514 40,319
656........................................... 3,739 56,790
657........................................... 7,946 38,780
658........................................... 7,957 31,512
659........................................... 4,484 50,404
660........................................... 7,985 36,216
661........................................... 4,264 28,963
662........................................... 998 41,878
663........................................... 2,288 29,568
664........................................... 4,543 21,878
665........................................... 693 47,261
666........................................... 2,405 30,788
667........................................... 3,765 17,825
668........................................... 3,768 39,776
669........................................... 13,307 27,864
670........................................... 12,685 17,652
671........................................... 917 28,789
672........................................... 940 17,260
673........................................... 12,678 43,365
674........................................... 13,848 38,562
675........................................... 8,371 31,105
682........................................... 76,428 30,069
683........................................... 128,229 25,154
684........................................... 28,358 16,191
685........................................... 2,520 18,480
686........................................... 1,596 31,266
687........................................... 3,467 24,382
688........................................... 1,098 16,621
689........................................... 55,794 25,693
690........................................... 201,347 16,948
691........................................... 908 32,141
692........................................... 653 23,510
693........................................... 2,256 27,791
694........................................... 19,345 16,454
695........................................... 982 24,103
696........................................... 10,646 13,740
697........................................... 585 16,016
698........................................... 21,255 27,734
699........................................... 27,064 21,858
700........................................... 11,141 15,265
707........................................... 6,053 34,784
708........................................... 15,996 27,483
709........................................... 796 33,829
710........................................... 2,015 28,079
711........................................... 953 34,060
712........................................... 793 18,806
713........................................... 12,009 24,773
714........................................... 32,647 14,452
715........................................... 662 34,122
716........................................... 1,367 26,199
717........................................... 666 31,542
718........................................... 601 17,543
722........................................... 881 29,202
723........................................... 2,078 23,886
724........................................... 648 14,696
725........................................... 808 23,735
726........................................... 3,956 15,110
727........................................... 1,106 26,438
728........................................... 6,224 15,600
729........................................... 603 22,575
730........................................... 533 13,176
734........................................... 1,528 39,574
735........................................... 1,278 24,152
736........................................... 842 68,949
737........................................... 3,487 39,556
738........................................... 912 26,791
739........................................... 980 48,297
740........................................... 4,638 31,766
741........................................... 6,330 22,182
742........................................... 11,685 29,942
743........................................... 34,686 19,452
744........................................... 1,634 28,687
745........................................... 2,080 18,005
746........................................... 2,664 27,898
747........................................... 11,073 19,176
[[Page 66892]]
748........................................... 21,289 18,499
749........................................... 1,048 42,978
750........................................... 477 22,403
754........................................... 1,097 31,885
755........................................... 3,219 24,350
756........................................... 783 15,311
757........................................... 1,326 31,206
758........................................... 1,659 24,086
759........................................... 1,141 17,474
760........................................... 1,815 17,766
761........................................... 1,844 12,285
765........................................... 2,606 19,738
766........................................... 2,664 13,500
767........................................... 123 14,158
768........................................... 10 28,544
769........................................... 87 30,064
770........................................... 188 15,884
774........................................... 1,476 11,268
775........................................... 5,343 8,224
776........................................... 495 14,028
777........................................... 180 17,674
778........................................... 494 7,925
779........................................... 107 12,859
780........................................... 50 5,097
781........................................... 3,062 11,922
782........................................... 129 7,495
790........................................... 1 10,892
793........................................... 1 7,090
799........................................... 631 76,408
800........................................... 730 45,534
801........................................... 581 35,405
802........................................... 693 51,922
803........................................... 1,030 33,848
804........................................... 978 23,443
808........................................... 8,276 34,018
809........................................... 15,783 25,043
810........................................... 3,694 19,852
811........................................... 18,481 24,822
812........................................... 83,743 16,735
813........................................... 15,112 25,412
814........................................... 1,649 29,868
815........................................... 3,483 23,384
816........................................... 2,274 16,506
820........................................... 1,490 83,924
821........................................... 2,593 40,916
822........................................... 2,108 28,993
823........................................... 2,452 64,964
824........................................... 3,130 40,720
825........................................... 1,940 29,726
826........................................... 566 77,536
827........................................... 1,354 40,320
828........................................... 851 29,066
829........................................... 1,386 44,486
830........................................... 520 24,753
834........................................... 5,293 50,536
835........................................... 1,458 30,848
836........................................... 1,554 23,636
837........................................... 1,638 86,041
838........................................... 942 41,650
839........................................... 1,368 27,174
840........................................... 15,248 37,709
841........................................... 11,355 28,818
842........................................... 7,431 22,926
843........................................... 1,498 32,726
844........................................... 2,893 25,240
845........................................... 988 19,989
846........................................... 2,498 37,638
847........................................... 23,816 25,436
848........................................... 1,695 18,894
849........................................... 1,507 27,052
853........................................... 31,591 74,820
854........................................... 6,945 49,005
855........................................... 429 35,456
856........................................... 6,215 64,154
857........................................... 10,284 36,043
858........................................... 3,362 28,370
862........................................... 7,481 32,201
863........................................... 21,957 20,215
864........................................... 19,959 19,205
865........................................... 2,032 28,153
866........................................... 9,474 15,750
867........................................... 5,387 37,627
868........................................... 2,507 24,427
869........................................... 1,129 18,549
870........................................... 13,815 88,107
871........................................... 204,810 33,501
872........................................... 92,533 25,285
876........................................... 971 40,709
880........................................... 10,578 14,303
881........................................... 4,636 10,640
882........................................... 1,673 11,353
883........................................... 799 16,323
884........................................... 21,747 17,521
885........................................... 78,937 14,233
886........................................... 377 13,044
887........................................... 427 17,908
894........................................... 4,627 7,335
895........................................... 6,777 14,018
896........................................... 5,447 25,226
897........................................... 36,860 12,339
901........................................... 924 48,983
902........................................... 2,217 31,794
903........................................... 1,687 22,773
904........................................... 980 39,791
905........................................... 779 24,032
906........................................... 751 22,406
907........................................... 8,164 53,029
908........................................... 8,553 34,813
909........................................... 5,427 25,547
913........................................... 828 26,581
914........................................... 7,082 15,123
915........................................... 928 24,288
916........................................... 5,418 9,886
917........................................... 14,498 28,189
918........................................... 35,052 13,329
919........................................... 10,672 28,054
920........................................... 14,259 20,512
921........................................... 9,672 13,742
922........................................... 1,027 26,694
923........................................... 4,264 14,600
927........................................... 187 176,359
928........................................... 819 59,807
929........................................... 448 32,905
933........................................... 158 31,820
934........................................... 701 23,903
935........................................... 2,209 21,647
939........................................... 428 42,892
940........................................... 732 32,945
941........................................... 1,058 25,659
945........................................... 5,485 19,140
946........................................... 2,759 16,452
947........................................... 6,597 22,649
948........................................... 34,624 14,331
949........................................... 767 17,139
950........................................... 463 11,233
951........................................... 1,008 13,228
955........................................... 456 82,569
956........................................... 3,769 54,324
957........................................... 1,324 98,399
958........................................... 1,221 65,730
959........................................... 295 44,733
963........................................... 1,509 46,426
964........................................... 2,538 32,437
965........................................... 1,105 23,186
969........................................... 676 74,072
970........................................... 159 41,796
974........................................... 6,358 38,864
975........................................... 4,516 27,898
976........................................... 2,770 20,952
977........................................... 5,016 23,376
981........................................... 26,444 75,197
982........................................... 19,320 52,409
983........................................... 6,143 37,918
984........................................... 671 56,061
985........................................... 1,108 38,816
986........................................... 833 27,982
987........................................... 8,040 53,190
988........................................... 12,302 35,697
989........................................... 6,162 25,762
999........................................... 30 11,270
------------------------------------------------------------------------
\1\ Cases taken from the FY 2006 MedPAR file; MS-DRGs are from GROUPER
Version 25.0.
[[Page 66893]]
Comparison of FY 2007 Standardized Amounts to the FY 2008 Single Standardized Amount With Full Update and Reduced Update
--------------------------------------------------------------------------------------------------------------------------------------------------------
Full update (3.3 percent); Full update (3.3 percent); Reduced update (1.3 percent); Reduced update (1.3
wage index is greater than wage index is less than wage index is greater than percent); wage index is less
1.0000 1.0000 1.0000 than 1.0000
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 2007 Base Rate, after Labor: $3,609.23............. Labor: $3,210.51............. Labor: $3,609.23............. Labor: $3,210.51
removing reclassification Nonlabor: $1,569.01.......... Nonlabor: $1,967.73.......... Nonlabor: $1,569.01.......... Nonlabor: $1,967.73.
budget neutrality,
demonstration budget
neutrality, wage index
transition budget neutrality
factors and outlier offset
(based on the labor and
market share percentage for
FY 2008).
FY 2008 Update Factor........ 1.033........................ 1.033........................ 1.013........................ 1.013.
FY 2008 DRG Recalibrations 0.996383..................... 0.996383..................... 0.996383..................... 0.996383.
and Wage Index Budget
Neutrality Factor.
FY 2008 Reclassification 0.991290..................... 0.991290..................... 0.991290..................... 0.991290.
Budget Neutrality Factor.
Adjusted for Blend of FY 2007 Labor: $3,682.49............. Labor: $3,275.68............. Labor: $3,611.20............. Labor: $3,212.26.
DRG Recalibration and Wage Nonlabor: $1,600.86.......... Nonlabor: $2,007.67.......... Nonlabor: $1,569.86.......... Nonlabor: $1,968.80.
Index Budget Neutrality
Factors.
Imputed Rural Floor Budget 0.999265..................... 0.999265..................... 0.999265..................... 0.999265.
Neutrality Factor.
FY 2008 Outlier Factor....... 0.948983..................... 0.948983..................... 0.948983..................... 0.948983.
Rural Demonstration Budget 0.999902..................... 0.999902..................... 0.999902..................... 0.999902.
Neutrality Factor.
FY 2008 Documentation and 0.994........................ 0.994........................ 0.994........................ 0.994.
Coding Adjustment.
Rural Floor Adjustment....... 1.002214..................... 1.002214..................... 1.002214..................... 1.002214.
Rate for FY 2008............. Labor: $3,478.45............. Labor: $3,094.17............. Labor: $3,411.10............. Labor: $3,034.26.
Nonlabor: $1,512.15.......... Nonlabor: $1,896.43.......... Nonlabor: $1,482.87.......... Nonlabor: $1,859.71.
--------------------------------------------------------------------------------------------------------------------------------------------------------
XX. Medicare Graduate Medical Education Affiliation Provisions for
Teaching Hospitals in Certain Emergency Situations
If you choose to comment on issues in this section, please include
the caption ``Medicare GME Affiliations'' at the beginning of your
comment.
A. Background
1. Legislative Authority
The stated purpose of section 1135 of the Act is to enable the
Secretary to ensure, to the maximum extent feasible, in any emergency
area and during an emergency period, that sufficient health care items
and services are available to meet the needs of enrollees in Medicare,
Medicaid, and the State Children's Health Insurance Program (SCHIP).
Section 1135 of the Act authorizes the Secretary, to the extent
necessary to accomplish the statutory purpose, to temporarily waive or
modify the application of certain types of statutory and regulatory
provisions (such as conditions of participation or other certification
requirements, program participation or similar requirements, or
preapproval requirements) with respect to health care items and
services furnished by health care provider(s) in an emergency area
during an emergency period.
The Secretary's authority under section 1135 of the Act arises in
the event there is an ``emergency area'' and continues during an
``emergency period'' as those terms are defined in the statute. Under
section 1135(g) of the Act, an emergency area is a geographic area in
which there exists an emergency or disaster that is declared by the
President according to the National Emergencies Act or the Robert T.
Stafford Disaster Relief and Emergency Assistance Act, and a public
health emergency declared by the Secretary according to section 319 of
the Public Health Service Act. (Section 319 of the Public Health
Service Act authorizes the Secretary to declare a public health
emergency and take the appropriate action to respond to the emergency,
consistent with existing authorities.) Throughout the remainder of this
discussion, we will refer to such emergency areas and emergency periods
as ``section 1135'' emergency areas and emergency periods.
Under section 1886(h) of the Act, as amended by section 9202 of the
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (Public
Law 99-272), the Secretary is authorized to make payments to hospitals
for the direct costs of approved GME programs. Section 1886(d)(5)(B) of
the Act provides for an additional payment per Medicare discharge for
acute care hospitals paid under the inpatient prospective payment
system (IPPS) that have residents in an approved GME program. This
additional payment is to reflect the higher patient care costs of
teaching hospitals, that is, the indirect graduate medical education
(IME) costs. Sections 1886(h)(4)(F) and 1886(d)(5)(B)(v) of the Act
establish limits on the number of allopathic and osteopathic residents
that hospitals may count for purposes of calculating direct GME
payments and the IME adjustment, respectively, establishing hospital-
specific direct GME and IME full-time equivalent (FTE) resident caps.
Under the authority granted by section 1886(h)(4)(H)(ii) of the Act,
the Secretary has issued rules to allow institutions that are members
of the same affiliated group to apply their direct GME and IME FTE
resident caps on an aggregate basis through a Medicare GME affiliation
agreement. The Medicare regulations at Sec. Sec. 413.75 and 413.79
permit hospitals, through a Medicare GME affiliation agreement, to
adjust IME and direct GME FTE resident caps to reflect the rotation of
residents among affiliated hospitals.
2. Existing Medicare Direct GME and Indirect GME Policies
The Medicare program makes payments to teaching hospitals to
account for two types of costs, the direct costs (direct GME) and the
indirect costs (IME) of a hospital's GME program. Direct GME payments
represent the direct costs of training residents (for
[[Page 66894]]
example, resident salaries and fringe benefits, and teaching physician
costs associated with an approved GME program) and generally are
calculated by determining the product of the Medicare patient load
(that is, the Medicare percentage of the hospital's inpatient days),
the hospital's per resident payment amount, and the weighted number of
FTE residents training at the hospital.
The IME adjustment is made to teaching hospitals for the additional
indirect patient care costs attributable to teaching activities. For
example, teaching hospitals typically offer more technologically
advanced treatments to their patients, and therefore, patients who are
sicker and need more sophisticated treatment are more likely to go to
teaching hospitals. Furthermore, there are additional costs associated
with teaching residents resulting from the additional tests or
procedures ordered by residents and the demands put on physicians who
supervise, and staff who support, the residents. IME payments are made
as a percentage add-on adjustment to the per discharge IPPS payment,
and are calculated based on the hospital's ratio of FTE residents to
available beds as defined at Sec. 412.105(b). The statutory formula
for calculating the IME adjustment is: c x [(1 + r).405 -
1], where ``r'' represents the hospital's ratio of FTE residents to
beds, and ``c'' represents an IME multiplier, which is set by the
Congress.
The amount of IME payment a hospital receives for a particular
discharge is dependent upon the number of FTE residents the hospital
trains, the hospital's number of available beds, the current level of
the statutory IME multiplier, and the otherwise payable per discharge
IPPS payment. Sections 1886(d)(5)(B)(v) and 1886(h)(4)(F) of the Act
established hospital-specific limits (that is, caps) on the number of
allopathic and osteopathic FTE residents that hospitals may count for
purposes of calculating indirect and direct GME payments, respectively.
3. Regulatory Changes Issued in 2006 To Address Certain Emergency
Situations
As explained above, when Hurricane Katrina occurred on August 29,
2005, disrupting health care operations and medical residency training
programs at teaching hospitals in New Orleans and the surrounding area,
the conditions were met to establish an emergency area and emergency
period under section 1135(g) of the Act. Shortly after Hurricane
Katrina occurred, we were informed by hospitals in New Orleans that the
training programs at many teaching hospitals in the city were closed as
a result of the disaster and that the displaced residents were being
transferred to training programs at host hospitals in other parts of
the country. For purposes of discussion in this rule, a host hospital
is a hospital that trains residents displaced from a training program
in a section 1135 emergency area. Also, a home hospital is one that
meets all of the following: (1) Is located in a section 1135 emergency
area (2) had its inpatient bed occupancy decreased by 20 percent or
more due to the disaster so that it is unable to train the number of
residents it originally intended to train in that academic year, and
(3) needs to send the displaced residents to train at a host hospital.
Section 413.79(h) allows a hospital that closed, or that closed one
or more of its residency training programs, to temporarily transfer FTE
residents and part or all of its FTE resident caps to another hospital
in order to allow the accepting hospital to count the displaced
residents for direct GME and IME payment and to enable the displaced
residents to complete their training despite closure of either the
hospital or the residency training program in which they were
originally training. In the aftermath of Hurricanes Katrina and Rita,
the training programs at many teaching hospitals in New Orleans and
surrounding areas were temporarily closed (or substantially reduced),
and the displaced residents were even transferred to other hospitals in
other parts of the country to continue their training programs. We
initially suggested that hospitals whose GME programs were affected by
Hurricanes Katrina and Rita could use these ``closed hospital'' and
``closed program'' regulations to address issues relating to displaced
residents. (We refer readers to the CMS Q&A's Web site at: http://questions.cms.hhs.gov. The Web site link is located at ID 5696.)
While a number of the residents have since returned to the
hurricane-affected hospitals, others remain displaced to other
hospitals, including hospitals located in States outside of the section
1135 emergency area. In response to immediate concerns relating to
displaced residents, CMS issued regulations on April 12, 2006 in an
interim final rule with comment period published in the Federal
Register (71 FR 18654). The regulatory changes in that rule allowed
home and host hospitals under certain circumstances to form emergency
Medicare GME affiliations. The purpose of these emergency Medicare GME
affiliation rules was to permit Medicare GME support to be maintained
while displaced residents are training at various hospitals, even as
the hurricane affected hospitals are rebuilding their training
programs. The modifications to the regulations at Sec. 413.75(b) and
Sec. 413.79(f) provided flexibility for home hospitals whose residency
programs have been disrupted in an emergency area to enter into
emergency Medicare GME affiliation agreements with host hospitals where
the hospitals may not meet the regulatory requirements for regular
Medicare GME affiliations. Due to the infrastructure damage and
continued disruption of operations experienced by medical facilities,
and the consequent disruption in residency training, caused by
Hurricanes Katrina and Rita in 2005, there became an urgent need for
these regulation changes to be applied retroactively.
Section 1871(e)(1)(A) of the Act, as amended by section 903(a)(1)
of the Medicare Prescription Drug, Improvement, and Modernization Act
of 2003 (MMA) (Public Law 108-173), generally prohibits the Secretary
from making retroactive substantive changes in policy unless
retroactive application of the change is necessary to comply with
statutory requirements, or failure to apply the change retroactively
would be contrary to the public interest. Because existing regulations
did not adequately address the issues faced by hospitals that are
located in the emergency areas, or hospitals that assisted by training
displaced residents from the emergency area, and because we believed
hospitals affected by Hurricanes Katrina and Rita would otherwise have
faced dramatic financial hardship and the recovery of graduate medical
education programs in the emergency area would have been impeded, we
found that failure to apply the regulatory changes in the April 12,
2006, interim final rule retroactively would be contrary to the public
interest. Thus, the provisions of this interim final rule were made
effective retroactively as of August 29, 2005.
To provide regulatory relief, especially in situations not
addressed under existing regulations (for example, where hospitals had
initially closed, but were in the process of gradually reopening their
programs, or where hospitals had severely reduced but never completely
closed their programs after Hurricanes Katrina and Rita), we
established the emergency Medicare GME affiliation provisions in the
April 12, 2006 interim final rule with comment period. In summary, the
April 12, 2006 interim final rule with comment period made changes as
follows:
[[Page 66895]]
To provide hospitals with more flexibility to train
displaced residents at various sites, and to allow host hospitals to
count displaced residents for IME and direct GME payment purposes, home
hospitals were permitted to enter into emergency Medicare GME
affiliation agreements effective retroactive to the date of the first
day of the section 1135 emergency period.
Home hospitals were permitted to affiliate with host
hospitals anywhere in the country. That is, a host hospital may be
located in any State and may receive a temporary adjustment to its FTE
caps to reflect displaced residents added or subtracted because the
hospital is participating in an emergency Medicare GME affiliated group
as defined at Sec. 413.75(b).
Emergency Medicare GME affiliation agreements were
required to be submitted to CMS with a copy to the CMS fiscal
intermediary or Medicare administrative contractor (MAC) by the later
of 180 days after the section 1135 emergency period begins or by July 1
of the academic year in which the emergency Medicare GME affiliation
agreement is effective. However, for hospitals affected by Hurricanes
Katrina and Rita, the deadline was subsequently extended to October 9,
2006. (We refer readers to the final rule published in the Federal
Register on July 6, 2006, for a detailed discussion (71 FR 38264
through 38266).
The effective period of the emergency Medicare GME
affiliation agreement was permitted to begin on or after the first day
of a section 1135 emergency period, and must terminate no later than at
the conclusion of 2 academic years following the academic year during
which the section 1135 emergency period began.
During the effective period of the emergency Medicare GME
affiliation agreement, hospitals in the emergency Medicare GME
affiliated group were not required to participate in a shared
rotational arrangement (as they would be under a regular Medicare GME
affiliation agreement).
Host hospitals were allowed an exception from the
otherwise applicable rolling average resident count for FTE residents
added as a result of an emergency Medicare GME affiliation agreement,
but only during the period from August 29, 2005 to June 30, 2006.
For a detailed discussion on each of the above emergency Medicare
GME affiliation provisions, we refer readers to the April 12, 2006
interim final rule with comment period. (71 FR 18654 through 18667).
In the April 12, 2006 interim final rule with comment period, we
revised the regulations at Sec. 413.79(f) to provide for more
flexibility than would have been possible under regular Medicare GME
affiliations to allow home hospitals to efficiently find training sites
for displaced residents. Under the flexibility provided by the
emergency Medicare GME affiliated group provisions as specified at
Sec. 413.79(f)(6), decisions regarding the transfer of FTE resident
cap slots, including how to distribute slots up to the home hospital's
FTE resident caps in situations where the home hospital was training a
number of residents in excess of its cap before the disaster, as well
as the tracking of those FTE resident slots, was left to the home and
host hospitals to work out among themselves. However, the home and host
hospitals were required to include much of this information in their
emergency Medicare GME affiliation agreements submitted both to CMS and
the CMS contractor, as specified under Sec. 413.79(f)(6). Furthermore,
since hospitals were permitted to amend their emergency Medicare GME
affiliation agreements (on or before June 30 of the relevant academic
year) to reflect the actual training situation among the hospitals
participating in the emergency Medicare GME affiliated group, hospitals
were provided with a great degree of flexibility to accommodate any
changing residency training circumstances within the emergency Medicare
GME affiliated group. We note that the emergency Medicare GME
affiliation provisions are intended for the purpose of enabling the
continued training of residents displaced from a section 1135 emergency
area, and not to enable hospitals to take advantage of the increased
flexibility in order to shift FTE resident cap slots to other hospitals
in the country (for instance, in order to maximize Medicare IME and
direct GME payments).
We stated in the April 12, 2006 interim final rule with comment
period that, in developing a policy to provide hospitals increased
flexibility in response to a disaster, we intended to address two
priorities. First, we believe that in disaster situations, to the
extent that the statute permits, the policy should facilitate the
continuity of GME, minimizing the disruption of residency training.
Second, the policy should take into account that the training programs
in the section 1135 emergency area have been severely disrupted by a
disaster and that the hospitals affected by the disaster will usually
want to rebuild their GME programs as soon as possible.
B. Additional Changes in This Interim Final Rule With Comment Period
1. Summary of Regulatory Changes
Since the establishment of the emergency provisions in the April
12, 2006 interim final rule with comment period, we have been
monitoring the application of the emergency Medicare GME affiliation
agreement rules in order to assess whether those regulatory changes
were adequate to address the needs of hospitals located in the section
1135 emergency area in the aftermath of Hurricanes Katrina and Rita. We
understand that hospitals with GME programs in the section 1135 area
continue to find it necessary to adjust the location of resident
training both within and outside the emergency area, as affected
hospitals continue to reopen beds at different rates, and as feedback
from accreditation surveys warrants educational adjustments.
Furthermore, stakeholders in Louisiana have informed CMS that they
believe fluidity in GME programs will continue for several more years,
and are not likely to stabilize until permanent replacement facilities
are established and functioning in the emergency area. As a result, we
believe the provisions first established in the April 12, 2006 interim
final rule need to be further modified to meet the two priorities
stated earlier. Therefore, through this interim final rule with comment
period, we are modifying the regulations for emergency Medicare GME
affiliated groups at Sec. 413.79(f)(6) to provide continuing relief to
home and host hospitals affected by disruptions in residency programs
in the section 1135 emergency area declared after Hurricanes Katrina
and Rita, as well as to provide relief for similar challenges in any
future emergency situation. We note that we did receive a number of
comments on the interim final rule with comment period issued on April
12, 2006. However, we believe it would be beneficial to provide the
public with the opportunity to submit formal comments on these latest
changes in the context of the current training situation in the area
affected by Hurricanes Katrina and Rita. We intend to respond to
comments submitted on both this interim final rule with comment period
and the April 12, 2006 interim final rule with comment period in a
future final rule.
Under existing regulations, the emergency Medicare GME affiliation
agreement must be written, signed, and dated by responsible
representatives of each participating hospital and must: (1) List each
participating hospital and its provider number, and specify whether the
hospital is a home or host hospital; (2) specify the effective period
of the
[[Page 66896]]
emergency Medicare GME affiliation agreement (which must, in any event,
terminate at the conclusion of two academic years following the
academic year in which the section 1135 emergency period began); (3)
list each participating hospital's IME and direct GME FTE caps in
effect for the current academic year before the emergency Medicare GME
affiliation (that is, if the hospital was already a member of a regular
Medicare GME affiliated group before entering into the emergency
Medicare GME affiliation, the emergency Medicare GME affiliation must
be premised on the FTE caps of the hospital as adjusted per the regular
Medicare GME affiliation agreement, and not include any slots gained
under section 422 of the MMA); and (4) specify the total adjustment to
each hospital's FTE caps in each year that the emergency Medicare GME
affiliation agreement is in effect, for both direct GME and IME, that
reflects a positive adjustment to the host hospital's direct and
indirect FTE caps that is offset by a negative adjustment to the home
hospital's (or hospitals') direct and indirect FTE caps of at least the
same amount. The sum total of all the participating hospitals' FTE caps
under the emergency Medicare GME affiliation agreement may not exceed
the aggregate adjusted caps of the hospitals participating in the
emergency Medicare GME affiliated group. A home hospital's IME and
direct GME FTE cap reduction under an emergency Medicare GME
affiliation agreement is limited to the home hospital's IME and direct
GME FTE resident caps in effect for the academic year, in accordance
with regulations at Sec. 413.79(c) or Sec. 413.79 (f)(1) through
(f)(5), that is, the hospital's base year FTE resident caps as adjusted
by any and all existing affiliation agreements in effect as of the
first day of the section 1135 period. Finally, as we stated in the
April 12, 2006 interim final rule with comment period, amendments to
the emergency Medicare GME affiliation agreement to adjust the
distribution of the FTE resident caps specified in the original
emergency Medicare GME affiliation among the hospitals that are part of
the emergency Medicare GME affiliated group in order to reflect the
actual placement of residents can be made through June 30 of the
academic year for which it is effective. [71 FR 18662]
In this interim final rule with comment period, we are further
modifying the regulations at Sec. 413.75(b) and Sec. 413.79(f) to
allow hospitals to enter into emergency Medicare GME affiliation
agreements with the following increased flexibility. First, for
emergency Medicare GME affiliation agreements involving a host hospital
located in a different State from the home hospital (hereinafter, an
``out-of-State host hospital''), the permissible effective period for
such agreements is extended from up to 3 years (i.e., the year in which
the section 1135 emergency period began plus two subsequent academic
years) to up to 5 years (i.e., the year in which the section 1135
emergency period began plus four subsequent academic years). However,
emergency Medicare GME affiliation agreements involving out of State
host hospitals during these two additional periods may only apply with
respect to the actual residents that were displaced from training in a
hospital located in the section 1135 emergency area. By ``actual
residents that were displaced from training in a hospital located in
the section 1135 area,'' we mean residents in an approved medical
residency training program at a home hospital at the time of the
disaster that were either actually training at the home hospital or
were scheduled to rotate to the home hospital during the training
program. For emergency Medicare GME affiliation agreements involving a
host hospital located in the same State as the home hospital
(hereinafter, an ``in-State host hospital''), the permissible effective
period for such agreements is extended from up to 3 years to up to 5
years for any resident (even those not displaced from training in a
hospital located in the 1135 emergency area). Emergency Medicare GME
affiliation agreements involving in-State host hospitals during these
additional two academic years need not apply only with respect to the
actual residents that were displaced immediately following the
disaster. In other words, such agreements may apply with respect to
residents that were actually displaced as a result of the disaster, as
well as to new residents that were not training in the program at the
time the disaster occurred. With the 2-year extension described above,
the effective period of an emergency Medicare GME affiliation agreement
may begin with the first day of a section 1135 emergency period, and
must terminate no later than at the end of the fourth academic year
following the academic year during which the section 1135 emergency
period began (for Hurricanes Katrina and Rita, this would be June 30,
2010). As home hospitals recover the ability to train residents after a
disaster, the effective period for emergency Medicare GME affiliation
agreements is intended to allow home hospitals to balance their desire
to return residents to their original training sites, with their need
to be given the opportunity to rebuild their programs incrementally. We
believe extending the applicability of emergency affiliations for out
of State host hospitals for 2 years (for a total of up to 5 years) only
for the actual residents displaced from home hospitals allows such
displaced residents to complete their training outside the affected
area while providing an incentive for home hospitals to begin training
new incoming residents locally (or closer to the home hospital),
increasing the likelihood for the residents to stay and practice in the
area after their training is completed. Affected hospitals in the New
Orleans area have informed CMS that residents will tend to go into
practice where they train. We believe this makes intuitive sense and
the policy established in this interim final rule with comment period
will provide additional impetus for residents to return to the State
where their ``home hospital'' is located, increasing the odds that the
physicians will stay and practice there, and encouraging regeneration
of the health care system affected by the section 1135 emergency. We
note that this is consistent with needs expressed by affected hospitals
in the New Orleans area for more physicians to replace the large
numbers that left immediately after the hurricane Furthermore, after
the expiration of the initial 3 years of the emergency Medicare GME
affiliation agreement effective period, we believe it would be
appropriate to begin bringing emergency Medicare GME affiliation rules
into accord with regular Medicare GME affiliation rules which specify
geographical limits. That is, regular Medicare GME affiliation rules
limit hospitals geographically to affiliations with other hospitals
that are located in the same urban or rural area (as those terms are
defined under Sec. 412.62(f)) or in a contiguous area.
In addition, home or host hospitals that have emergency Medicare
GME affiliation agreements and are training displaced residents in
nonhospital sites are permitted to submit written agreements with
nonhospital sites, as described under Sec. 413.78, that may be
effective beginning with the first day of the section 1135 emergency
period to cover the displaced residents training at nonhospital sites.
We discuss the policy for training that occurs in the nonhospital
setting and the requirements for written agreements in further detail
in the following section. However, in brief, this interim final rule
with comment period provides hospitals
[[Page 66897]]
that are participating in emergency Medicare GME affiliation agreements
with increased flexibility in submitting written agreements relating to
training that occurs in nonhospital sites. Home or host hospitals with
valid emergency Medicare GME affiliation agreements training displaced
residents in a nonhospital site may submit a copy of the written
agreement, as specified under Sec. 413.78(e)(iii) and (f)(iii) as
applicable, to the CMS contractor servicing the hospital by 180 days
after the first day the resident began training at the nonhospital
site. We note that, as with the existing rules for written agreements
specified at Sec. 413.78(f), adjustments to the amounts specified (in
other words, the total program costs and the portion of certain costs
to be incurred by the hospital) in the written agreement can be made
through June 30 of the academic year for which it is effective.
Furthermore, under current rules, hospitals that are training
residents at nonhospital sites have two options as specified by the
regulations at Sec. 413.78(e). That is, hospitals must either have a
written agreement in place before the training occurs or they must pay
``all or substantially all'' of the costs for the training program in
the nonhospital setting attributable to training that occurs during a
month by the end of the third month following the month in which the
training in the nonhospital site occurred. We discuss this ``concurrent
payment'' option in more detail in the following section. In this
interim final rule with comment period, we are providing additional
flexibility in the ``concurrent payment'' option for home or host
hospitals that have emergency Medicare GME affiliation agreements and
are training displaced residents in nonhospital sites by extending the
time allowable for ``concurrent payment'' from 3 months to 6 months.
That is, a home or host hospital with a valid emergency Medicare GME
affiliation agreement is permitted to incur ``all or substantially
all'' of the costs for the training program in the nonhospital setting
attributable to training that occurs during a month by the end of the
sixth month following the month in which the training in the
nonhospital site occurred.
In the case of the section 1135 emergency resulting from Hurricanes
Katrina and Rita, the time limit we are adopting to submit written
agreements or to meet the ``concurrent payment'' requirement may have
already passed. Therefore, as discussed in detail in the following
section, we are providing that, for residents training in nonhospital
sites during the period of August 29, 2005, to November 1, 2007, home
or host hospitals with valid emergency Medicare GME affiliation
agreements may submit written agreements or incur ``all or
substantially all'' of the costs of the training program (that is, the
``concurrent payment'' option) to cover those specific residents by
April 29, 2008.
Based on what we have learned about the impact of a disaster on
teaching hospitals, we continue to believe it is necessary to provide
hospitals with greater flexibility to distribute FTE resident caps
within a group of home and host hospitals if there is an emergency at a
home hospital resulting in the designation of a section 1135 emergency
area. We believe that this modified emergency Medicare GME affiliation
policy will allow affected hospitals an appropriate degree of
flexibility following the disaster so that residents displaced by the
disaster can continue their residency training at other hospitals,
while the home hospitals can remain committed to reopening their
programs.
Emergency Medicare GME affiliation agreements should be submitted
to: Centers for Medicare & Medicaid Services, Division of Acute Care,
Attention: Elizabeth Truong or Renate Rockwell,Mailstop C4-08-06, 7500
Security Boulevard, Baltimore, MD 21244.
``Emergency Medicare GME Affiliation Agreement'' should be clearly
labeled on the outside envelope.
2. Discussion of Training in Nonhospital Settings
Under the existing regulations at Sec. 413.78(e) and (f), for
portions of cost reporting periods occurring on or after October 1,
2004, the time residents spend in nonhospital settings such as
freestanding clinics, nursing homes, and physicians' offices in
connection with approved programs may be included in determining the
hospital's number of FTE residents for purposes of calculating both
direct GME and IME payments, if all of the following conditions are
met:
(1) The resident spends his or her time in patient care activities.
(2) The hospital incurs ``all or substantially all'' of the costs
for the training program in the nonhospital setting. In the May 11,
2007 final rule (72 FR 26948), we revised the definition of ``all or
substantially all of the costs for the training program in the
nonhospital setting'' to mean: (a) Effective on or after January 1,
1999 and for cost reporting periods beginning before July 1, 2007, the
residents'' salaries and fringe benefits (including travel and lodging
where applicable) and the portion of the cost of teaching physicians''
salaries and fringe benefits attributable to direct graduate medical
education (GME); and (b) effective for cost reporting periods beginning
on or after July 1, 2007, at least 90 percent of the total of the costs
of the residents'' salaries and fringe benefits (including travel and
lodging where applicable) and the portion of the cost of teaching
physicians'' salaries attributable to non-patient care direct GME
activities.
(3) There is a written agreement between the hospital and the
nonhospital site that indicates that the hospital will incur the costs
of the resident's salary and fringe benefits while the resident is
training in the nonhospital site, and the hospital is providing
reasonable compensation to the nonhospital site for supervisory
teaching activities. The agreement must indicate the compensation the
hospital is providing to the nonhospital site for supervisory teaching
activities. In addition, in the same May 11, 2007 final rule cited
above, we clarified the regulations at Sec. 413.78(f)(3)(ii) to
specify that the written agreement must be in place between the
hospital and the nonhospital site before the training begins in that
nonhospital site. We also specified that the written agreement must
specify the total cost of the training program in the nonhospital site,
the amount of the total cost that the hospital will incur (at least 90
percent of the total cost of the training program), and must indicate
the portion of the amount the hospital will incur that reflects
residents'' salaries and fringe benefits (and travel and lodging where
applicable), and the portion of the amount the hospital will incur that
reflects teaching physician compensation. Furthermore, we revised the
regulations to indicate that the amounts specified in the written
agreement may be modified by June 30 of the applicable academic year.
(4) Alternatively, for portions of cost reporting periods occurring
on or after October 1, 2004, hospitals have two options as specified by
the regulations at Sec. 413.78(e). Hospitals must either have a
written agreement in place before the training occurs or they must
incur ``all or substantially all'' of the costs for the training
program in the nonhospital setting attributable to training that occurs
during a month by the end of the third month following the month in
which the training in the nonhospital site occurred (the ``concurrent
payment'' option).
For a more detailed discussion on the requirements a hospital must
meet in order to count residents training in
[[Page 66898]]
nonhospital sites for IME and direct GME payment purposes, we refer
readers to the May 11, 2007 final rule (72 FR 26948 through 26977).
Recently, it has come to our attention that in the wake of
Hurricanes Katrina and Rita, host hospitals, many of which received
large numbers of displaced residents, were hard-pressed to find
training sites for these unanticipated residents. Many host hospitals
called upon community physician practices, clinics, and other
nonhospital settings to supplement existing training locations and
accommodate the displaced residents. Some of the host hospitals that
took in displaced residents had never before had any residency training
programs, and were therefore new to Medicare rules regarding graduate
medical education. In the haste and confusion surrounding this
unprecedented displacement of residents, many host hospitals arranged
for displaced residents to begin training in nonhospital sites without
first establishing a written agreement, as specified in Sec.
413.78(e), between the hospital and nonhospital site. Similarly, home
hospitals that may have sent some of their residents away to train at
host hospitals while continuing to train a reduced number of residents
in the home hospital program, may find that the usual nonhospital sites
for the residents in that program have also been negatively affected by
the disaster. Consequently, home hospitals may have hastily arranged
for displaced residents to begin training in nonhospital sites and due
to the reduced administrative capability in the aftermath of the
disaster, home hospitals may not have been able to establish a written
agreement, as specified in Sec. 413.78(e), with the nonhospital site
before residents started training in the nonhospital site. Also, in the
confusion and haste under which arrangements were made for displaced
residents to train in nonhospital sites, many hospitals did not
actually incur all or substantially all of the costs of the training
program in the nonhospital site in accordance with our regulations at
Sec. 413.78(e)(3)(i) or (f)(3)(i).
In the April 12, 2006 interim final rule with comment period, we
did not specifically mention the policies that pertain to training in
nonhospital sites, although we did indicate that, to determine direct
GME and IME payments under an emergency Medicare GME affiliation, all
of the normal rules for counting FTEs as specified at Sec. 413.78
apply. Based on what we have learned since the occurrence of Hurricanes
Katrina and Rita, we believe it would be appropriate to provide home
hospitals that have been adversely affected by the disaster and host
hospitals that accept residents pursuant to an emergency Medicare GME
affiliation agreement greater flexibility in the timeframes for
compliance with our nonhospital site policies. Consequently, we are
providing additional flexibility in regards to the submission of
written agreements by home and host hospitals by specifying in this
interim final rule with comment period that home or host hospitals with
a valid emergency Medicare GME affiliation agreement may submit the
written agreement required under our regulations even after the
residents have begun training at the nonhospital site. The submission
deadline for written agreements after a disaster is subject to the
following requirements: (1) A home or host hospital must be
participating in a valid emergency Medicare GME affiliation and (2) a
home or host hospital training displaced residents in a nonhospital
site must submit a copy of the written agreement, subject to the
requirements of a written agreement as specified under Sec. 413.78
(e)(iii) or (f)(iii) as applicable, to the CMS fiscal intermediary or
MAC servicing the hospital by 180 days after the first day the resident
began training at the nonhospital site. We are also specifying that
amendments to the written agreement can be made through June 30 of the
academic year for which it is effective.
Furthermore, as we discussed above, under current rules hospitals
that are training residents at nonhospital sites have the option of
paying ``all or substantially all'' of the costs for the training
program in the nonhospital setting attributable to training that occurs
during a month by the end of the third month following the month in
which the training in the nonhospital site occurred. For the same
reasons cited above supporting our belief that it is appropriate to
extend the deadline to submit written agreements after a disaster, we
are also providing additional flexibility in the ``concurrent payment''
option for home or host hospitals that have emergency Medicare GME
affiliation agreements and are training displaced residents in
nonhospital sites by extending the time allowable for ``concurrent
payment'' from 3 months to 6 months. That is, a home or host hospital
with a valid emergency Medicare GME affiliation agreement is permitted
to pay ``all or substantially all'' of the costs for the training
program in the nonhospital setting attributable to training that occurs
during a month by the end of the sixth month following the month in
which the training in the nonhospital site occurred.
In the case of Hurricanes Katrina and Rita, the time limits we are
adopting regarding the submission of written agreements to cover
residents training in nonhospital sites for home or host hospitals with
a valid emergency Medicare GME affiliation agreement may have already
passed. Therefore, we are providing that a home or host hospitals with
valid emergency Medicare GME affiliation agreements may submit written
agreements to cover residents training in nonhospital sites during the
period of August 29, 2005, to November 1, 2007, by April 29, 2008.
Similarly, for residents training in nonhospital sites during the
period of August 29, 2005, to November 1, 2007, home or host hospitals
with valid emergency Medicare GME affiliation agreements may pay ``all
or substantially all'' of the costs of the training program (i.e., the
``concurrent payment'' option) to cover those specific residents by
April 29, 2008.
C. Response to Comments on the April 12, 2006 Interim Final Rule With
Comment Period and This Interim Final Rule With Comment Period
We note that we did receive a number of comments on the interim
final rule with comment issued on April 12, 2006. We believe it would
be beneficial to provide the public with the opportunity to submit
formal comments on the latest changes in this interim final rule with
comment period in the context of the current training situation in the
area affected by Hurricanes Katrina and Rita. We intend to respond to
comments submitted on both this interim final rule with comment period
(to be submitted as specified in the ADDRESSES section of this
document) and the April 12, 2006 interim final rule with comment period
in a future final rule.
XXI. Files Available to the Public Via the Internet
A. Information in Addenda Related to the Revised CY 2008 Hospital OPPS
Addenda A and B to this final rule with comment period provide
various data pertaining to the CY 2008 payment for items and services
under the OPPS. Addendum A, which includes a complete list of all APCs
payable under the OPPS, and Addendum B, which includes a complete list
of all active HCPCS codes for CY 2008 and all currently active HCPCS
codes that will be discontinued at the end of CY 2007 with assigned
payment status and comment indicators, are available to the
[[Page 66899]]
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.
Addendum D1 defines payment status indicators that are used in
Addenda A and B. Addendum D2 defines comment indicators that are used
in Addendum B. Addendum E lists HCPCS codes that are only payable as
inpatient procedures and are not payable under the OPPS. Addendum L
contains the out-migration wage adjustment for CY 2008. Addendum M
lists the HCPCS codes that are members of a composite APC and
identifies the composite APC to which they are assigned. This addendum
also identifies the status indicator for the code and a comment
indicator if there has been a change in the code's status with regard
to its membership in the composite APC. Each of the HCPCS codes
included in Addendum M has a single procedure payment APC, listed in
Addendum B, to which it is assigned when the criteria for assignment to
the composite APC are not met. When the criteria for payment of the
code through the composite APC are met, one unit of the composite APC
payment is paid, thereby providing packaged payment for all services
that are assigned to the composite APC according to the specific
Outpatient Code Editor (OCE) logic that applies to the APC. We refer
readers to the discussion of composite APCs in section II.A.4.d of this
final rule with comment period for a complete description of the
composite APCs.
Those addenda and other supporting OPPS data files are available on
the CMS Web site at: http://www.cms.hhs.gov/HospitalOutpatientPPS/.
B. Information in Addenda Related to the Revised CY 2008 ASC Payment
System
Addenda AA, BB, DD1, and DD2 to this final rule with comment period
provide various data pertaining to the ASC covered surgical procedures
and the covered ancillary services for which ASCs may receive separate
payment beginning in CY 2008 when the ancillary service provided in the
ASC is integral to a covered surgical procedure and provided
immediately before, during, or immediately following the covered
surgical procedure. All relative payment weights and payment rates are
final for CY 2008 as a result of applying the revised ASC payment
system methodology established in the final rule for the revised ASC
payment system published in the Federal Register on August 2, 2007 (72
FR 42470) to the final CY 2008 OPPS and MPFS ratesetting information.
Addendum DD1 defines the payment indicators that are used in
Addenda AA and BB to this final rule with comment period. Addenda AA
and BB provide payment information regarding covered surgical
procedures and covered ancillary services under the revised ASC payment
system. Addendum DD2 defines the comment indicators that we are using
to provide additional information about the status of ASC covered
surgical procedures and covered ancillary services.
Addendum EE (available only on the Internet) lists the surgical
procedures that are excluded from Medicare payment in ASCs. The
excluded procedures listed in Addendum EE are surgical procedures that
either are assigned to the OPPS inpatient list, are not covered by
Medicare, are reported using a CPT unlisted code, or are determined to
pose a significant safety risk or are expected to require an overnight
stay when performed in ASCs.
Those addenda and other supporting ASC data files are included on
the CMS Web site at: http://www.cms.hhs.gov/ASCPayment/ in a format
that can be easily downloaded and manipulated. The final ASC relative
weights and payment rates for CY 2008 are published in this CY 2008
OPPS/ASC final rule with comment period, and related data files are
included on the CMS Web site as noted above. MPSF data files are
located at http://www.cms.hhs.gov/PhysicianFeeSched/.
The links to all of the FY 2008 IPPS wage index related tables
(that are used for the CY 2008 OPPS) from the FY 2008 IPPS final rule
with comment period (72 FR 47436 through 47539) as corrected in the
October 10, 2007 Federal Register notice to the FY 2008 IPPS final rule
with comment period (72 FR 57634 through 57738) are accessible on the
CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/
list.asp#TopOfPage.
For additional assistance, contact Chuck Braver, (410) 786-6719.
XXII. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to
provide 30-day notice in the Federal Register and solicit public
comment when a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. In
order to fairly evaluate whether an information collection should be
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act
of 1995 (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.
In the CY 2008 OPPS/ASC proposed rule, we solicited public comment
on each of these issues for the following sections included in the
proposed rule that contain information collection requirements.
Section 419.43(h) Adjustment to national program payment and
beneficiary copayment amounts: Applicable adjustments to conversion
factor for CY 2009 and for subsequent calendar years
Section 419.43(h) requires hospitals, in order to qualify for the
full annual update, to submit quality data to CMS, as specified by CMS.
In the proposed rule, we proposed the specific requirements related to
the data that must be submitted for the update for CY 2009. The burden
associated with this section is the time and effort associated with
collecting and submitting the data, completing participating forms and
submitting charts. We estimate that there will be approximately 3,500
respondents per year.
For hospitals to collect and submit the information on the required
measures, we estimate it will take 30 minutes per sampled case.
Further, based on an estimated ten percent sample size and estimated
populations of 2.5-5 million outpatient visits per measure, we estimate
a total of 1,800,000 cases per year. In addition, we estimate that
completing participation forms with require approximately 4 hours per
hospital per year. We expect the burden for all of these hospitals to
total 914,000 hours per year.
In this final rule with comment period, for CY 2009, we have
delayed implementation of our validation process which will require
participating hospitals to submit 5 charts. The burden associated with
this requirement is the time and effort associated with collecting,
copying, and submitting these charts. It will take approximately 2
hours per hospital to submit the 5 charts. There will be a total of
approximately 17,500 charts (3,500
[[Page 66900]]
hospitals x 5 charts per hospital) submitted by the hospitals to CMS
for a total burden of 7,000 hours. However, as noted above, this
validation process will not apply for the CY 2009 update. Therefore, we
expect the total burden for all hospitals for the CY 2009 updates to be
921,000 hours per year.
In section XVII.J. of this final rule with comment period, we are
finalizing a provision from the FY 2008 IPPS final rule with comment
period relating to the FY 2009 RHQDAPU quality measure set to include
SCIP Infection 4: Cardiac Surgery Patients with Controlled 6AM
Postoperative Serum Glucose and SCIP Infection 6: Surgery Patients with
Appropriate Hair Removal, bringing the total number of measures in that
measure set to 30.) The burden associated with the collection of these
two measures was included in the burden estimates in the FY 2008 IPPS
final rule with comment period (72 FR 47409 and 48169). There is no
additional burden imposed in this final rule with comment period.
Section 482.22 Condition of participation: Medical staff
We proposed under Sec. 482.22(c)(5)(i) to require that a medical
history and physical examination be completed and documented no more
than 30 days before or 24 hours after admission or registration, but
prior to surgery or a procedure requiring anesthesia services, for each
patient by a physician (as defined in section 1861(r) of the Act), an
oromaxillofacial surgeon, or other qualified licensed individual in
accordance with State law and hospital policy.
The burden associated with this requirement is the time and effort
it would take for medical staff to document the patient's medical
history and the results of a physical examination. While the burden
associated with this proposed requirement is subject to the PRA, we
believe the burden is exempt as defined in 5 CFR 1320.3(b)(2) because
the time, effort, and financial resources necessary to comply with the
requirement would be incurred by persons in the normal course of their
activities.
We proposed under Sec. 482.22(c)(5)(ii) to require that an updated
examination of the patient, including any changes in the patient's
condition, be completed and documented within 24 hours after admission
or registration, but prior to surgery or a procedure requiring
anesthesia services, when the medical history and physical examination
are completed within 30 days before admission or registration. The
updated examination must also be completed and documented by the
individuals as required under Sec. 482.22(c)(5)(i).
The burden associated with this proposed requirement is the time
and effort it would take for medical staff to document any changes in
the patient's condition. While the burden associated with this proposed
requirement is subject to the PRA, we believe the burden is exempt as
defined in 5 CFR 1320.3(b)(2) because the time, effort, and financial
resources necessary to comply with the requirement would be incurred by
persons in the normal course of their activities.
Section 482.24 Condition of participation: Medical record services
We proposed under Sec. 482.24(c)(2)(i) to require evidence of:
(A) A medical history and physical examination completed and
documented no more than 30 days before or 24 hours after admission or
registration, but prior to surgery or a procedure requiring anesthesia
services. The medical history and physical examination must be placed
in the patient's medical record within 24 hours after admission or
registration, but prior to surgery or a procedure requiring anesthesia.
(B) An updated examination of the patient, including any changes in
the patient's condition, when the medical history and physical
examination are completed within 30 days before admission or
registration. Documentation of the updated examination must be placed
in the patient's medical record within 24 hours after admission or
registration, but prior to surgery or a procedure requiring anesthesia
services.
While the burden associated with these two proposed requirements is
subject to the PRA, we believe the burden is exempt as defined in 5 CFR
1320.3(b)(2) because the time, effort, and financial resources
necessary to comply with the requirement would be incurred by persons
in the normal course of their activities.
Section 482.51 Condition of participation: Surgical services
We proposed under Sec. 482.51(b)(1) to require medical staff,
prior to surgery or a procedure requiring anesthesia services, and
except in the case of emergencies, to document no more than 30 days
before or 24 hours after admission or registration a patient's medical
history, the results of the patient's physical examination, and any
changes in the patient's condition.
While the burden associated with these requirements is subject to
the PRA, we believe the burden is exempt as defined in 5 CFR
1320.3(b)(2) because the time, effort, and financial resources
necessary to comply with the requirement would be incurred by persons
in the normal course of their activities.
Section 482.52 Condition of participation: Anesthesia services
We proposed under Sec. 482.52(b)(1) to require a preanesthesia
evaluation to be completed and documented by an individual qualified to
administer anesthesia, performed within 48 hours prior to surgery or a
procedure requiring anesthesia services. We proposed under Sec.
482.52(b)(3) to require a postanesthesia evaluation to be completed and
documented by an individual qualified to administer anesthesia, after
surgery or a procedure requiring anesthesia services, but before
discharge or transfer from the postanesthesia recovery area.
As discussed in section XVIII.B.2. of this final rule with comment
period, in response to public comments, we have revised Sec.
482.52(b)(3) to specify that a postanesthesia evaluation must be
completed and documented no later than 48 hours after surgery or a
procedure requiring anesthesia services. The postanesthesia evaluation
must be completed in accordance with State law and with hospital
policies and procedures that are approved by the medical staff and that
reflect current standards of anesthesia care.
While the burden associated with these requirements is subject to
the PRA, we believe the burden is exempt as defined in 5 CFR
1320.3(b)(2) because the time, effort, and financial resources
necessary to comply with the requirement would be incurred by persons
in the normal course of their activities.
In section XX. of this document, we are specifying the requirement
for the submittal of emergency Medicare GME affiliation agreements
under the provisions of Sec. 413.79(f) of the regulations by hospitals
in declared emergency areas. The burden associated with this
requirement is the time and effort it would take for the GME affiliated
hospital to develop and submit the emergency Medicare GME affiliation
agreement. It is difficult for us to determine estimated annual burden
because we do not know how many hospitals will be affected in any given
disaster. It would depend on what resources are available to the
affected hospitals after sustaining damage from the disaster. This
could take a few hours per hospital or much longer depending on if they
keep records available and current. Hospitals also have to coordinate
with other hospitals to draw up an affiliation agreement which may
[[Page 66901]]
take more time if the hospitals have to negotiate.
We have submitted a copy of this final rule with comment period and
this interim final rule with comment period to OMB for its review of
the information collection requirements described above. These
requirements are not effective until they have been approved by OMB.
If you comment on these information collection and recordkeeping
requirements, please mail copies directly to the following:
Centers for Medicare & Medicaid Services, Office of Strategic
Operations and Regulatory Affairs, Division of Regulations Development,
Attn: Melissa Musotto, (CMS-1392-FC for OPPS/ASC matters, or CMS-1531-
IFC2, for Medicare GME Affiliation Agreement matters) 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-1392-FC for OPPS/ASC
matters, or CMS-1531-IFC2, for Medicare GME Affiliation Agreement
matters carolyn--lovett@ omb.eop.gov. Fax (202) 395-6974.
XXIII. 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 final rule
with comment period, and, when we proceed with a subsequent
document(s), we will respond to those comments in the preamble to that
document(s).
XXIV. 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, Public Law 96-354), section 1102(b) of the Social Security
Act, the Unfunded Mandates Reform Act of 1995 (Public Law 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 would be
implemented by this final rule with comment period will result in
expenditures exceeding $100 million in any 1 year. 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 2008 compared to CY 2007 to be approximately $3.4
billion.
We estimate that implementing the revised ASC payment system in CY
2008 based on the August 2, 2007 final rule for the revised ASC payment
system and the final policies in this CY 2008 OPPS/ASC final rule with
comment period (such as adding 11 procedures to the ASC list of covered
surgical procedures and designating 18 additional procedures as office-
based) will have no net effect on Medicare expenditures in CY 2008
compared to the level of expenditures that would have occurred in CY
2008 in the absence of the revised payment system. A more detailed
discussion of the effects of the changes to the ASC list of covered
surgical procedures and the effects of the revisions to the ASC payment
system in CY 2008 is provided in section XXIV.C. of this final rule
with comment period.
While we estimate that there will be no net change in Medicare
expenditures in CY 2008 as a result of implementing the revised ASC
payment system and the ASC provisions of this final rule with comment
period, we estimate that the revised system will result in savings of
$220 million over 5 years due to migration of new ASC covered surgical
procedures from HOPDs and physicians' offices to ASCs over time. In
addition, we note that there will be a total increase in Medicare
payments to ASCs of approximately $240 million for CY 2008 compared to
Medicare expenditures that would have occurred in the absence of the
revised payment system. These additional payments to ASCs of
approximately $240 million in CY 2008 will be fully offset by savings
from reduced Medicare spending in HOPDs and physicians' offices on
services that migrate from these settings to ASCs, as described in
detail in section XVI.L. of this final rule with comment period.
Our estimate in this final rule with comment period of 5-year
savings as a result of the revised ASC payment system and our estimate
of additional payments to ASCs in CY 2008 differ slightly from the
estimates presented in the August 2, 2007 revised ASC payment system
final rule. The ASC budget neutrality adjustment and the resulting
savings estimates in the August 2, 2007 final rule are calculated using
CY 2005 utilization data, the current CY 2007 OPPS relative weights
with an estimated update factor for CY 2008, and the CY 2007 MPFS PE
RVUs trended forwarded to CY 2008. The ASC budget neutrality adjustment
and the resulting savings estimates in this final rule with comment
period are calculated using the newly available CY 2006 utilization
data, the CY 2008 OPPS relative payment weights finalized in this final
rule with comment period, and the CY 2008 MPFS PE RVUs finalized in the
CY 2008 MPFS final rule. As we indicated in the August 2, 2007 revised
ASC payment system final rule, the estimates in that rule were meant to
be illustrative of the final policies only, in large part because we
used the existing CY 2007 OPPS relative payment weights and the
existing CY 2007 MPFS PE RVUs to estimate the CY 2008 values. Because
the savings estimates in this final rule with comment period are based
on the final CY 2008 OPPS relative payment weights that have just
become available in this final rule with comment period and the final
CY 2008 MPFS PE RVUs that recently became available in the CY 2008 MPFS
final rule with comment period, the estimates in this final rule with
comment period based on that newly available information represent our
best estimates at this time.
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 jurisdictions. Most
hospitals and most other providers and suppliers are small entities,
either by nonprofit status or by having average annual revenues of $31
million or less.
For purposes of the RFA, we have determined that approximately 37
percent of hospitals and 73 percent of
[[Page 66902]]
ASCs would be considered small entities according to the Small Business
Administration (SBA) size standards. (We refer readers to the standards
at the Web site: http://www.sba.gov/idc/groups/public/documents/serv_sstd_tablepdf.pdf). 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 2,141 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 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 (Public Law 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 rule 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. The changes to the ASC payment system for CY
2008 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 (Public Law
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. This
final rule with comment period does not mandate any requirements for
State, local, or tribal government, nor does 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 61, we
estimate that OPPS payments to governmental hospitals (including State
and local governmental hospitals) will increase by 3.9 percent under
this final rule with comment period. The provisions related to payments
to ASCs in CY 2008 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, 2008, as we discuss in sections II.C.
and II.D., respectively, of this final rule with comment period. We
also are revising the relative APC payment weights using claims data
from January 1, 2006, through December 31, 2006, 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 final rule with
comment period provides greater detail on this rural adjustment.
Finally, we are removing one device category, HCPCS code C1820
(Generator, neurostimulator, (implantable), with rechargeable battery
and charging system), from pass through payment status in CY 2008.
Under this final rule with comment period, the update change to the
conversion factor as provided by statute will increase total OPPS
payments by 3.3 percent in CY 2008. The one time wage reclassification
under section 508 expired September 30, 2007, and therefore, is not
contemplated in this final rule with comment period. The changes to the
APC weights, including the changes that will result from the expansion
of packaging, changes to the wage indices, and the continuation of a
payment adjustment for rural SCHs and EACHs with extension to
brachytherapy sources in CY 2008 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 61 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 the 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 the Packaging Policies for CY 2008 OPPS
In section II.A.4.c. of this final rule with comment period, we are
packaging payment for the following seven categories of ancillary and
supportive services into payment for the independent service with which
they are billed. We are also making payment for several composite APCs
in which a single payment is made for multiple major services that are
commonly performed on the same date. We discuss below each category of
services that we are packaging and each set of services for which we
are establishing a composite APC.
(1) Guidance Services
We are packaging payment for supportive guidance services into the
payment for the independent procedure to which the guidance service is
ancillary and supportive. In the case of one particular guidance
procedure, which would usually be provided in conjunction with another
independent procedure but may occasionally be provided without another
independent service on the same date of service, we
[[Page 66903]]
will permit separate payment if the service is billed without an
independent procedure on the same date of service. We refer readers to
section II.A.4.c.(1) of this final rule with comment period for the
complete discussion of this final policy. We considered several policy
options for the payment of guidance services in CY 2008.
The first alternative we considered was to not make any changes to
packaging for the CY 2008 OPPS. Under this alternative, codes that were
packaged for CY 2007 would have remained packaged for CY 2008 and codes
that were separately paid for CY 2007 would have remained separately
paid for CY 2008. There are a number of CPT codes that describe
independent surgical procedures for which the code descriptors indicate
that guidance is included in the code reported for the surgical
procedure if it is used and, therefore, for which the OPPS already
makes packaged payment for the associated guidance service. With a
number of guidance services already packaged, we did not select this
option in part because we did not want to create financial incentives
for hospitals to use one form of guidance instead of another or to use
guidance all the time, even if a procedure could be safely provided
without guidance. Furthermore, we believe this alternative would not
provide additional incentives for hospitals to utilize the most cost-
effective and clinically advantageous method of guidance that is
appropriate in each situation.
The second alternative we considered was to package the costs of
guidance services in all cases, without regard to the possibility of
the service being furnished without an independent service on the same
date of service. We did not select this alternative because we believe
that in the case of one particular guidance procedure, the procedure
may sometimes be appropriately furnished without other independent
services on the same date and in these cases, we believe that there
should be separate payment for the guidance service.
The third alternative we considered, and the alternative we
selected, was to unconditionally package payment for most supportive
guidance services, while allowing separate payment for one particular
guidance service when that guidance service is furnished without an
independent service. When guidance services are furnished as an
ancillary and supportive adjunct to an independent procedure, we are
packaging payment for all guidance procedures. When one specific
guidance service (which is occasionally not provided in conjunction
with an independent procedure on the same date of service) is not
provided on the same date as an independent procedure, we will pay
separately for that service. We believe that this alternative will
provide the most appropriate incentives to control volume and spending
for these services, without discouraging the performance of the service
in those infrequent cases when one particular guidance service is
provided without an independent procedure.
(2) Image Processing
We are packaging payment for image processing services into the
payment for the major independent service to which the image processing
service is ancillary and supportive. We refer readers to section
II.A.4.c.(2) of this final rule with comment period for the complete
discussion of this final policy. We considered several policy options
for the payment of image processing services in CY 2008.
The first alternative we considered was to make no changes to
packaging for the CY 2008 OPPS. Under this alternative, codes that were
packaged for CY 2007 would have remained packaged for CY 2008 and codes
that were separately paid for CY 2007 would have remained separately
paid for CY 2008. We did not select this alternative because we believe
it would not provide additional incentives for hospitals to utilize the
most cost-effective and clinically advantageous image processing
services that are appropriate in each situation.
The second alternative we considered was to package the costs of
image processing services in cases in which the image processing
service is furnished on the same date as an independent service to
which the image processing service is ancillary and supportive but to
pay separately for the image processing service when it is furnished
without an independent service on the same date of service. We did not
select this alternative because it would not have provided substantial
additional incentives for hospitals to utilize image processing in the
most cost-effective and clinically advantageous manner.
The third alternative we considered, and ultimately selected, was
to package payment for the costs of image processing services in all
cases, without regard to the possibility of the service being furnished
without an independent service on the same date of service. While an
image processing service is not necessarily provided on the same date
of service as the independent procedure to which it is ancillary and
supportive, providing separate payment for each imaging processing
service whenever it is performed is not consistent with encouraging
value-based purchasing under the OPPS. We believe it is important to
package payment for supportive dependent services that accompany
independent procedures but that may not need to be provided face-to-
face with the patient in the same encounter as the independent service.
Packaging encourages hospitals to establish protocols that ensure that
services are furnished only when they are medically necessary and to
carefully scrutinize the services ordered by practitioners to minimize
unnecessary use of hospital resources. Therefore, we believe that this
alternative will provide additional appropriate incentives to control
volume and spending for these services, without discouraging the use of
the service in those infrequent cases when it is provided with an
independent procedure but on a different date of service.
(3) Intraoperative Services
We are packaging payment for intraoperative services into the
payment for the independent procedure to which the intraoperative
service is ancillary and supportive. In the case of two intraoperative
services, which would usually be provided in conjunction with another
independent procedure but may occasionally be provided without another
independent service on the same date of service, we will permit
separate payment if the services are billed without an independent
procedure on the same date of service. We refer readers to section
II.A.4.c.(3) of this final rule with comment period for the complete
discussion of this final policy. We considered several policy options
for the payment of intraoperative services in CY 2008.
The first alternative we considered was to make no changes to
packaging for the CY 2008 OPPS. Under this alternative, codes that were
packaged for CY 2007 would have remained packaged for CY 2008 and codes
that were separately paid for CY 2007 would have remained separately
paid for CY 2008. We did not select this alternative because we believe
it would not provide additional incentives for hospitals to utilize the
most cost-effective and clinically advantageous intraoperative services
that are appropriate in each situation.
The second alternative we considered was to package payment for the
costs of intraoperative services in all cases, without regard to the
possibility of the service being furnished without an independent
service on the same date of
[[Page 66904]]
service. We did not select this alternative because we believe that, in
the case of two particular intraoperative procedures, those procedures
may sometimes be appropriately furnished without other independent
services on the same date and, in these cases, we believe that there
should be separate payment for the intraoperative services.
The third alternative we considered, and ultimately selected, was
to unconditionally package the costs of intraoperative services in all
cases except two, to allow for the possibility of these two
intraoperative services being furnished without an independent service
on the same date of service. We believe that there is some possibility
that these procedures could be appropriately performed without another
independent procedure on the same date of service. We do not believe
this to be true of the other intraoperative services that we proposed
to unconditionally package. We selected this alternative because we
believe it unlikely that intraoperative services other than the two
particular services would ever be provided without an independent
service. Packaging encourages hospitals to establish protocols that
ensure that services are furnished only when they are medically
necessary and to carefully scrutinize the services ordered by
practitioners to minimize unnecessary use of hospital resources. We
believe that this is the most appropriate alternative because, in
general, it creates additional incentives for hospitals to provide
intraoperative services only when both medically necessary and cost
efficient for the individual patient. Therefore, we believe that this
alternative will provide the most appropriate incentives to control
volume and spending for these services.
(4) Imaging Supervision and Interpretation Services
We are unconditionally packaging payment for some imaging
supervision and interpretation services into the payment for the
independent service to which the imaging supervision and interpretation
service is ancillary and supportive and conditionally packaging payment
for other imaging supervision and interpretation services when the
independent service has a status indicator of ``T.'' For this latter
subset of codes, we are permitting separate payment if there is no
service with status indicator of ``T'' billed the same date of service.
We refer readers to section II.A.4.c.(4) of this final rule with
comment period for the complete discussion of this final policy. We
considered several policy options for the payment of imaging
supervision and interpretation services in CY 2008.
The first alternative we considered was to make no changes to
packaging for the CY 2008 OPPS. Under this alternative, codes that were
packaged for CY 2007 would have remained packaged and codes that were
separately paid for CY 2007 would have remained separately paid for CY
2008. We did not select this alternative because we believe it would
not provide additional incentives for hospitals to utilize the most
cost effective and clinically advantageous imaging supervision and
interpretation services that are appropriate in each situation.
The second alternative we considered was to unconditionally package
imaging supervision and interpretation procedures that we believe are
always integral to and dependent upon an independent separately payable
procedure, but to conditionally package payment for those imaging
supervision and interpretation services that we believe are sometimes
furnished without another separately payable service on the same date.
We did not accept this alternative because commenters convinced us that
to do this would sometimes result in packaging these services with
services for which packaging of the imaging supervision and
interpretation services was inappropriate (for example, visits and
minor diagnostic tests).
The third alternative we considered, and the alternative we
selected, was to unconditionally package imaging supervision and
interpretation procedures that we believe are always integral to and
dependent upon an independent separately payable procedure, but to
conditionally package payment for certain imaging supervision and
interpretation services only when they are provided on the same date of
service as a service with a status indicator of ``T.'' We believe that
this alternative is the most appropriate choice because it creates
additional incentives for hospitals to provide services only when
medically necessary to an individual patient when the supervision and
interpretation service is furnished as an ancillary and supportive
adjunct to the independent procedural service and does not package the
payment for the supervision and interpretation service with the payment
for a visit or other service. We will pay separately for some imaging
supervision and interpretation services in those cases where they are
not furnished on the same date as a service with status indicator of
``T.'' Therefore, we believe that this alternative will provide the
most appropriate incentives to control volume and spending for these
services, without discouraging the performance of the services in those
cases when they are furnished with a service with a status indicator
other than ``T.''
(5) Diagnostic Radiopharmaceuticals
We are packaging payment for diagnostic radiopharmaceuticals into
the payment for their associated nuclear medicine procedures. In
response to comments, we are using only claims for nuclear medicine
procedures that contain a Level II HCPCS code for a diagnostic
radiopharmaceutical to set the median costs for the nuclear medicine
services, and we are implementing claims processing edits that require
that a nuclear medicine service must have a diagnostic
radiopharmaceutical HCPCS code on the same claim to be accepted for
processing. We refer readers to section II.A.4.c.(5) of this final rule
with comment period for the complete discussion of this final policy.
We considered several policy options for the payment of diagnostic
radiopharmaceuticals in CY 2008.
The first alternative we considered was to make no changes to our
packaging methodology for diagnostic radiopharmaceuticals in the CY
2008 OPPS. Under this alternative, diagnostic radiopharmaceuticals with
a mean per-day cost of $60 or less would be packaged into the payment
for associated procedures present on the claim. Diagnostic
radiopharmaceuticals with a per-day cost over $60 would receive
separate payment. We did not select this alternative because we believe
it would not provide additional incentives for hospitals to utilize the
most cost-effective and clinically advantageous diagnostic
radiopharmaceuticals that are appropriate in each situation.
The second alternative we considered was to package the costs of
diagnostic radiopharmaceuticals in cases in which the diagnostic
radiopharmaceutical is furnished on the same date as an independent
service to which the diagnostic radiopharmaceutical is ancillary and
supportive, but to pay separately for the diagnostic
radiopharmaceutical when it is furnished without an independent service
on the same date of service. We did not select this alternative because
diagnostic radiopharmaceuticals are always intended to be used with a
diagnostic nuclear medicine procedure. Our claims data indicate that
diagnostic radiopharmaceuticals are infrequently provided on a
different date of service from a nuclear medicine procedure. Because
our standard OPPS ratesetting
[[Page 66905]]
methodology packages costs across dates of service on ``natural''
single claims, we believe that our standard methodology adequately
captures the costs of diagnostic radiopharmaceuticals associated with
diagnostic nuclear medicine procedures that are not provided on the
same date of service.
The third alternative we considered, and the alternative we
selected, was to package the costs of diagnostic radiopharmaceuticals
with their associated nuclear medicine procedures, to calculate the
median costs of nuclear medicine procedures using only claims that
contain a Level II HCPCS code for a diagnostic radiopharmaceutical, and
to implement claims processing edits that require that a claim that
reports a code for a nuclear medicine procedure must also contain a
code for a diagnostic radiopharmaceutical to be accepted for
processing. Packaging the costs of supportive items and services into
the payment for the independent procedure or service with which they
are associated encourages additional hospital efficiencies and enables
hospitals to better manage their resources with maximum flexibility.
Diagnostic radiopharmaceuticals are always intended to be used with a
diagnostic nuclear medicine procedure, and are, therefore, particularly
well suited for packaging under the OPPS for the reasons identified in
section II.A.4.c.(5) of this final rule with comment period. Moreover,
calculating the median cost of nuclear medicine procedures using only
claims that also contain at least one diagnostic radiopharmaceutical
will ensure that the cost of the radiopharmaceuticals used in the
procedure will be captured in the median cost. In addition,
implementing a claims processing edit that will require that a claim
that contains a code for a nuclear medicine procedure must also contain
a code for a diagnostic radiopharmaceutical will ensure that in future
years, all claims for nuclear medicine procedures will include the cost
of the radiopharmaceuticals used to furnish the service.
(6) Contrast Media
We are packaging payment for contrast media into their associated
independent diagnostic and therapeutic procedures. We refer readers to
section II.A.4.c.(6) of this final rule with comment period for the
complete discussion of this final policy. We considered several policy
options for the payment of contrast media in CY 2008.
The first alternative we considered was to make no changes to our
packaging methodology for contrast media in the CY 2008 OPPS. Under
this alternative, contrast media with a mean per-day cost of $60 or
less would be packaged into the payment for associated procedures
present on the claim. Contrast media with a per-day cost over $60 would
receive separate payment. We did not select this alternative because we
believe it would not provide additional incentives for hospitals to
utilize contrast media in the most cost-effective and clinically
advantageous manner. With most contrast media already packaged based on
our $60 packaging threshold, this alternative would potentially
maintain inconsistent payment incentives across similar products.
The second alternative we considered was to package the costs of
contrast media in cases in which the contrast medium is furnished on
the same date as an independent service but to pay separately for the
contrast medium when it is furnished without an independent service on
the same date of service. We did not select this alternative because we
believe it is unlikely that contrast media would ever be provided
without an independent service on the same date of service.
The third alternative we considered, and the alternative we
selected, was to unconditionally package the costs of contrast media
with their associated independent diagnostic and therapeutic
procedures. The vast majority of contrast media will currently be
packaged under the $60 packaging threshold. Given that most contrast
agents will already be packaged under the OPPS in CY 2008, we believe
it would be desirable to package payment for the remaining contrast
agents, as this approach promotes additional efficiency and results in
a more consistent payment policy across products that may be used in
many of the same independent procedures. In the case of
echocardiography procedures that are performed with contrast, we have
established separate Level II HCPCS codes to report these services, so
that we will pay for contrast and noncontrast studies through separate
APC groups as section 1833(t)(2)(G) of the Act requires. The median
cost of the APC for noncontrast echocardiography services was set based
on those claims for the studies that also reported a contrast agent, to
ensure that the procedure payment includes the cost of the necessary
contrast agent.
(7) Observation Services
We are packaging payment for all observation care, reported under
HCPCS code G0378 (Hospital observation services, per hour) for CY 2008.
Payment for observation will be packaged as part of the payment for the
separately payable services with which it is billed. In addition, we
created two additional composite APCs for extended assessment and
management, of which observation care is a component. We refer readers
to section II.A.4.c.(7) of this final rule with comment period for the
complete discussion of this final policy. We considered several policy
options for the payment of observation services in CY 2008.
The first alternative we considered was to make no changes to
payment of observation services for the CY 2008 OPPS. Since January 1,
2006, hospitals have reported observation services based on an hourly
unit of care using HCPCS code G0378. This code has a status indicator
of ``Q'' under the CY 2007 OPPS, meaning that the OPPS claims
processing logic determines whether the observation is packaged or
separately payable. The OCE's current logic determines whether
observation care billed under G0378 is separately payable through APC
0339 (Observation), or whether payment for observation services will be
packaged into the payment for other separately payable services
provided by the hospital in the same encounter based on criteria
discussed in more detail in section II.A.4.c.(7) of this final rule
with comment period. For CY 2007, we continued to apply the criteria
for separate payment for observation care and the coding and payment
methodology for observation care that were implemented in CY 2006. We
did not select this alternative because the current criteria for
separate payment for observation services treat payment for observation
care for various clinical conditions differently and may provide
disincentives for efficiency. In addition, there has been substantial
growth in program expenditures for hospital outpatient services under
the OPPS in recent years, a trend that is reflected in the rapidly
increasing volume of claims for separately payable observation
services. This alternative would not provide additional incentives for
hospitals to utilize observation services in the most cost effective
and clinically advantageous manner.
The second alternative we considered was to accept the APC Panel's
recommendations to add syncope and dehydration to the list of diagnoses
eligible for separate payment or to consider other clinical conditions
for separate payment for observation care. We believe that, in certain
circumstances, observation could be appropriate for patients with a
range of
[[Page 66906]]
diagnoses. Both the APC Panel and numerous commenters to prior OPPS
proposed rules have confirmed their agreement with this perspective.
However, as packaging payment provides additional desirable incentives
for more efficient delivery of health care and provides hospitals with
significant flexibility to manage their resources, we believe it is
most appropriate to treat observation care for all diagnoses similarly
by packaging its costs into payment for the separately payable
procedures with which the observation is associated. Consequently, we
did not select this alternative to expand separate observation payment
to additional diagnoses.
The third alternative we considered was to package payment for all
observation services reported with HCPCS code G0378 under the CY 2008
OPPS. We believe this is the most appropriate alternative within the
context of our packaging approach because observation is always
provided as a supportive service in conjunction with other independent
separately payable hospital outpatient services such as an emergency
department visit, surgical procedure, or another separately payable
service, and thus its costs can be packaged into the OPPS payment for
such services. We believe that packaging payment into larger payment
bundles creates incentives for providers to furnish services in the
most efficient way that meets the needs of the patient, encouraging
long-term cost containment. With approximately 70 percent of the
occurrences of observation care billed under the OPPS currently
packaged, this alternative will extend the incentives for efficiency
already present for the vast majority of observation care that is
already packaged under the OPPS to the remaining 30 percent of
observation care for which we currently make separate payment.
However, based on the public comments we received, while we are
adopting our proposal to package payment for all observation services
reported with HCPCS code G0378 under the CY 2008 OPPS, we will also
create two additional composite APCs for extended assessment and
management, of which observation care is a major component. This
refinement of the third alternative responds to commenters who stated
that observation care is sometimes a major component of a patient's
visit. We continue to believe that observation services are usually
ancillary and supportive to the other independent services that are
provided to the patient on the same day. However, we believe that
observation care may sometimes rise to the level of a major component
service, specifically, when it is provided for 8 hours or more in
association with a high level clinic or emergency department visit,
direct admission to observation, or critical care services and it is
not provided in conjunction with a surgical procedure. Therefore, we
have created two composite APCs that will provide payment to hospitals
in certain circumstances when extended assessment and management of a
patient occur. These composite APCs describe an extended encounter for
care provided to a patient. Specifically, we are creating two new
composite APCs for CY 2008, APC 8002 (Level I Extended Assessment and
Management Composite) and APC 8003 (Level II Extended Assessment and
Management Composite). The payment associated with APCs 8002 and 8003
is intended to pay the hospital for the costs associated with a single
episode of care involving more intense extended assessment and
management that includes a high level clinic or emergency department
visit, direct admission to observation, or critical care services; 8
hours or more of observation services; and any associated packaged
services.
In summary, for CY 2008, payment for observation services will
remain packaged with a status indicator ``N.'' We are creating two
composite APCs for extended assessment and management, of which
observation care is a major component service. When criteria for
payment of one of the composite APCs are met, separate payment will be
made to the hospital through the composite APC. This composite APC
payment methodology will contribute to our goal of providing payment
under the OPPS for a larger bundle of component services provided in a
single hospital outpatient encounter, creating additional hospital
incentives for efficiency and cost containment, while providing
hospitals with the most flexibility to manage their resources.
(8) Composite APCs
We are establishing five composite APCs for the CY 2008 OPPS. In
addition to the two composite APCs that we proposed for the CY 2008
OPPS and for which we discuss the alternatives considered in this
section, we have also created two composite APCs for extended
assessment and management (of which observation care is a part), and we
identify APC 0034 (Mental Health Services Composite), the longstanding
limit on per diem payment for mental health services, as a composite
APC. We refer readers to the discussion of alternatives considered for
observation services, above, and to section II.A.4.c.(7) of this final
rule with comment period for further discussion of the composite APCs
of which observation is a part. We refer readers to section II.A.4.d.
of this final rule with comment period for a discussion of APC 0034.
A composite APC is an APC that provides a single payment for
several independent services when they are furnished on the same date
of service. Composite APCs are intended to establish APC payment rates
for combinations of services that are frequently furnished together so
that the multiple procedure claims on which they are submitted may be
used to set the payment rates for them and so that the payment for the
services provides greater incentives for efficient use of hospital
resources. Specifically, as proposed, we are establishing composite APC
8000 for low dose rate prostate brachytherapy (which will be paid when
CPT codes 55875 (Transperineal placement of needles or catheters into
prostate for interstitial radioelement application, with or without
cystoscopy) and 77778 (Interstitial radiation source application;
complex) are billed on the same date of service) and APC 8001 for
cardiac electrophysiologic evaluation and ablation services (which will
be paid when at least one designated cardiac electrophysiologic
evaluation service is billed on the same date as at least one
designated cardiac ablation service). We refer readers to sections
II.A.4.d.(2) and II.A.4.d.(3) of this final rule with comment period
for a detailed discussion of the policies for these APCs. We note that
we will continue to pay individual services under their single
procedure APCs as we have in the past, in those clinical circumstances
in which the combinations of services proposed for payment through the
composite APCs are not furnished on the same date. We considered two
alternatives with regard to creating composite APCs.
The first alternative we considered was to make no change to how we
pay for these services. If we were to make no change, we could continue
to pay separately for each service. We did not select this alternative
because the payment rates would continue to be based on single
procedure claims, which we have been told by stakeholders do not
represent the typical treatment scenario. Interested parties have
repeatedly told us, and our examination of claims data supports, that
these services are typically furnished in combination with one another
and, therefore, this may suggest that the use of single procedure
claims
[[Page 66907]]
to establish the median costs that form the basis for payment for these
services may result in our using clinically unusual or incorrectly
coded claims as the basis for payment.
The second alternative we considered, and the alternative we
selected, is to create composite APCs for these services, which are
commonly furnished in combination with one another, and to make a
single payment for the multiple services specified in the composite APC
at a prospectively established rate based on the total cost of the
combination of services furnished. This alternative responds to public
comments that multiple procedure claims for these services that we have
heretofore been unable to use for ratesetting reflect the most common
treatment scenarios. It also provides additional incentives for
efficient provision of services by bundling payment for multiple
services into a single payment. Composite APCs enable us to use more of
our claims data and to use single procedure claims only to set payment
rates for the uncommon circumstances in which a particular service is
not furnished in combination with other related independent services.
Therefore, we are establishing composite APCs 0034, 8000, 8001, 8002,
and 8003 for the CY 2008 OPPS.
b. Partial Device Credits
We are reducing payment by 50 percent of the device offset amount
for specified APCs when hospitals report that they have received a
credit for a replacement device of greater than or equal to 50 percent
of the cost of the new replacement device being implanted, if the
device is on a list of specified devices. We refer readers to section
IV.A.3. of this final rule with comment period for a complete
discussion of this final policy. This is an extension of the current
policy that reduces the APC payment by the full device offset amount
when the hospital receives a replacement device without cost or
receives a credit for the full cost of the device being replaced. We
considered several alternatives in developing this partial device
credit policy for CY 2008.
The first alternative we considered was to make no change to the
current policy. Under this alternative, Medicare and the beneficiary
would continue to pay the full APC rate, which is calculated using only
claims for which the full cost of a device is billed by the hospital,
even if the hospital received a substantial credit towards the cost of
the replacement device. We did not select this alternative because we
believe that, as long as the APC payment amount is initially
established to reflect the full cost of the device when there is no
credit, there should be a reduction in the Medicare payment amount when
the hospital receives a substantial credit toward cost of the
replacement device. Similarly, we believe that the beneficiary cost
sharing should be based on an amount that also reflects the credit.
The second alternative we considered was to extend the current
policy to cases of partial credit without change. This would reduce the
payment in all cases in which the hospital received a credit by the
full offset amount for the APC, that is, by 100 percent of the
estimated device cost contained in the APC. We considered this
alternative because, in our discussions with hospitals about partial
credits for devices, they advised us that hospitals generally charge
the same amount for a device regardless of whether they receive a
significant amount in credit towards the cost of that device. Hence, in
such a case the costs that are packaged into the APC payment for the
applicable procedure contain the same amount of device cost as if the
hospital incurred the full cost of the device. We did not select this
alternative because we did not believe it was appropriate to reduce the
payment to the hospital by the full cost of a device if the hospital
only received a partial credit, and not a full credit, towards the cost
of the device.
The third alternative we considered was to reduce the APC payment
by 50 percent of the offset amount (that would be applied if the
hospital received full credit) in cases in which the hospital receives
a partial credit of 20 percent or more of the cost of the new
replacement device being implanted. We would require hospitals to
report a new modifier when the hospital receives a partial credit that
is 20 percent or more of the cost of the device being replaced. We are
not adopting this policy, which we proposed in the CY 2008 OPPS/ASC
proposed rule, for several reasons. We note it would not be consistent
with the FY 2008 IPPS partial credit device policy, and we were
concerned that 20 percent is a nominal portion of the cost of a device
and would not justify the administrative and operational burden posed
by the policy and, accordingly, the 50-percent payment reduction would
be more than the partial credit received in some cases.
The fourth alternative, which we are adopting, is a modification of
the third alternative described above. This alternative is to reduce
the APC payment by 50 percent of the offset amount (that would be
applied if the hospital received full credit) in cases in which the
hospital receives a partial credit of 50 percent or more of the cost of
the new replacement device being implanted. We are requiring hospitals
to report the ``FC'' modifier when the hospital receives a partial
credit that is 50 percent or more of the cost of the device being
replaced. We are adopting this alternative because we believe that this
approach provides an appropriate and equitable payment to the hospital
from Medicare and, depending on the service, may reduce the
beneficiary's cost sharing for the service.
c. Brachytherapy Sources
Pursuant to sections 1833(t)(2)(H) and 1833(t)(16)(C) of the Act,
we paid for brachytherapy sources furnished from January 1, 2004
through December 31, 2006, 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. Moreover, pursuant to section 107(a) of the MIEA-
TRHCA, which amended section 1833(t)(16)(C) of the Act by extending the
payment period for brachytherapy sources based on a hospital's charges
adjusted to cost, we are paying for brachytherapy sources using the
charges adjusted to cost methodology through December 31, 2007. Section
107(b)(1) of the MIEA-TRHCA amended section 1833(t)(2)(H) of the Act,
by adding a requirement for the establishment of separate payment
groups for ``stranded and non-stranded'' brachytherapy devices
beginning July 1, 2007. In section VII.B. of this final rule with
comment period, we are adopting prospective payment for all
brachytherapy sources under the CY 2008 OPPS, including separate
payment for stranded and non-stranded versions of sources currently
known to us, that is, iodine-125, palladium-103 and cesium-131. For
each of the sources for which we have information that only non-
stranded source versions are marketed, we are making payment based on
the median cost per source based on our CY 2006 claims data. For
sources for which we have information that both stranded and non-
stranded versions are marketed and for which our CY 2006 billing codes
do not differentiate stranded and non-stranded sources, we are basing
payment for stranded and non-stranded brachytherapy sources on the 60th
percentile and 40th percentile of our claims data, respectively, for CY
2008. We discuss each alternative we considered below.
The first alternative we considered was to pay for each source of
brachytherapy based on our CY 2006 median costs, with the exception of
the 3 sources for which we do not have separately reported cost data
for their
[[Page 66908]]
stranded and non-stranded versions, that is, iodine-125, palladium-103,
and cesium-131. Under this option, for these six stranded and non-
stranded sources, we considered payment based on hospital charges
reduced to cost for CY 2008. This approach would be a step toward
prospective payment for brachytherapy sources, as the sources that only
have non-stranded versions would receive prospective payment consistent
with the overall OPPS methodology. However, payment for stranded and
non-stranded iodine-125, palladium-103 and cesium-131 would deviate
from the overall OPPS framework for prospective payment and from the
prospective payment of the non-stranded only sources specifically. This
approach would subject similar items that are essential to
brachytherapy treatments to different payment methodologies and could
potentially create financial incentives for the use of some products
over others.
The second alternative we considered was to continue making
payments for all sources based on hospital charges reduced to cost.
Although hospitals are familiar with this payment methodology and this
methodology would be consistent with the requirement that brachytherapy
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 hospitals
to provide brachytherapy treatments in the most cost-effective and
clinically advantageous manner.
The third alternative we considered, and the alternative we
selected, is to provide prospective payment for each brachytherapy
source based on its median costs. For the sources which only have non-
stranded versions, we are using our standard median cost methodology.
For the 3 sources that have stranded and non-stranded versions and for
which we do not yet have separately reported stranded and non-stranded
claims data, we are calculating the median costs based on the
assumption that the reportedly lower cost non-stranded sources would be
unlikely to be in the top 20 percent of the cost distribution of our
aggregate CY 2006 claims data for each respective source, and on the
assumption that the reportedly higher cost stranded sources would be
unlikely to be in the bottom 20 percent of the CY 2006 cost
distribution for each source. This approach to calculating median costs
for stranded and non-stranded iodine-125, palladium-103, and cesium-131
sources results in Medicare payment rates based on the 60th percentile
of our aggregate data for stranded sources and the 40th percentile of
our aggregate data for non-stranded sources. This methodology provides
for separate payment of all sources, including stranded and non-
stranded sources, recognizes a cost differential between stranded and
non-stranded sources, is consistent with our prospective payment
methodology for setting payment rates for other services, and is
consistent with the expiration of the requirement of the MIEA-TRHCA
that payment for brachytherapy sources be made at charges reduced to
cost through December 31, 2007.
2. Limitations of Our Analysis
The distributional impacts presented here are the projected effects
of the policy changes on various hospital groups. We post our hospital-
specific estimated payments for CY 2008 with the other supporting
documentation for this final rule with comment period. To view the
hospital-specific estimates, we refer readers to the Web site at:
http://www.cms.hhs.gov/HospitalOutpatientPPS/. Select ``regulations and
notices'' from the left side of the page and then select CMS-1392-FC
from the list of regulations and notices. The hospital-specific file
layout and the hospital-specific file are listed with the other
supporting documentation for this final rule with comment period. We
show hospital-specific data only for hospitals whose claims were used
for modeling the impacts shown in Table 61. We do not show hospital-
specific impacts for hospitals whose claims we were unable to use. We
refer readers to Section II.A.2. of this final with comment period for
a discussion of the hospitals whose claims we do not use for
ratesetting and impact purposes.
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 changes on hospitals and our methodology for estimating
them. We discuss below several specific limitations of our analysis.
One limitation of our analysis is our inability to estimate
behavioral responses to our increase in packaging and our payment for
multiple procedures based on one composite payment rate. Specifically,
it is possible that there could be a behavioral response to our final
policy to package payment for guidance services, image processing
services, intraoperative services, imaging supervision and
interpretation services, diagnostic radiopharmaceuticals, contrast
agents, and observation services, and to pay for certain services
through composite APCs when the services are furnished in specified
combinations. However, we are unable to estimate what the effect of
possible behavioral responses may be on payment to hospitals. We refer
readers to section II.A.4. of this final rule with comment period for
further discussion of the packaging approach. The purpose of packaging
these services and creating composite APCs is to remove financial
incentives to furnish additional services and, instead, to provide
greater incentives for hospitals to assess the most cost-effective and
appropriate means to furnish necessary services. In addition, we expect
that hospitals will negotiate for lower prices from suppliers to
maximize the margin between their cost of providing services and the
Medicare payment for the services. We recognize that it is also
possible that hospitals could change behavior in a manner that seeks to
overcome any reductions in total payments by ceasing to provide certain
packaged services on the same date of service and instead requiring
patients to receive those services on different dates of service or at
different locations, so as to either receive separate additional
payment for services that would otherwise be packaged or to not incur
the additional costs of those services. However, we believe that this
will be uncommon for several reasons. We anticipate that hospitals will
continue to provide care that is aligned with the best interests of the
patient. In the vast majority of cases for the services that are newly
unconditionally packaged in CY 2008, the services need to be provided
in the same facility and during the same encounter as the independent
procedure they support. Furthermore, in the case of conditionally
packaged services, we note that the supportive services that we have
included in our packaging policies are typically services that are
provided during or shortly preceding the independent procedure to which
they are ancillary and supportive, and thus it is unlikely that the
supportive service that is packaged and the independent procedure will
be performed in different locations. However, we are unable to quantify
the extent to which such behavioral change may impact Medicare payments
to hospitals.
[[Page 66909]]
Secondly, we are not able to estimate the impact on hospitals of
our policy to reduce payment when a hospital receives a partial credit
for a medical device that fails while under warranty or otherwise. We
do not currently require hospitals to notify us when they received a
partial credit for a device for which they are billing. In addition,
hospitals have informed us that hospitals generally do not currently
reduce the charge for a device when they receive a partial credit
toward the device for which they are billing Medicare. Therefore, we
have no means of knowing the frequency with which this happens or the
extent to which hospitals' costs for the devices being replaced are
reduced as a result of the partial credits and cannot estimate the
impact of the policy on hospital payments under the OPPS in CY 2008.
Third, we are unable to estimate the extent to which hospitals will
incur no cost for devices or will receive full or partial credits for
devices being replaced as a result of the failure of the device. In CY
2006, hospitals reported the ``FB'' modifier on codes for devices that
they received without cost or for which they received a full credit.
However, we are unable to forecast the extent to which the frequency or
the type of device for which this occurred in CY 2006 will recur for CY
2008. We believe that most of these occurrences were the result of
specific activity that we have no reason to believe will occur in CY
2008 at the same frequency at which it occurred in CY 2006, and hence
we have made no estimates of how such activity may impact payments to
hospitals. Similarly, we have no estimate of the extent to which
hospitals will receive partial credits for devices under warranty
actions in CY 2008. Beginning January 1, 2008, hospitals will report
cases in which they receive a partial credit for a device if the credit
is 50 percent or more of the cost of the replacement device. However,
these data will not be available until the development of the CY 2010
OPPS, which will be based on CY 2008 claims.
Fourth, for purposes of this impact analysis, for those
brachytherapy sources with new codes to distinguish between stranded
and non-stranded version, we assume that half of the brachytherapy
sources that hospitals will use in CY 2008 will be stranded sources and
that half of them will be non-stranded sources. The statute requires us
to pay for stranded and non-stranded sources through different APC
groups, but given the lack of separately reported claims data for
stranded and non-stranded sources, for the purposes of this impact
analysis, we make this assumption. In the CY 2008 OPPS/ASC proposed
rule, we welcomed data that would provide the expected CY 2008 ratio of
stranded sources to non-stranded sources for purposes of this CY 2008
final rule impact analysis. We did not receive any information
regarding the ratio of stranded to non-stranded sources in the public
comments on the proposed rule.
The final limitation of our analysis is that we cannot predict the
utilization of new CY 2007 and CY 2008 CPT codes that replace existing
CY 2006 CPT codes for which we have cost data on which we base the CY
2008 OPPS payment rates. In years past, we have estimated the impact of
these code changes as if the deleted codes would continue to exist for
the applicable year for which we were estimating impacts. For this
final rule with comment period, we applied the AMA's estimates of new
code utilization which are used for the MPFS final rule with comment
period. However, we do not know whether these estimates of physician
utilization are equally applicable to hospital outpatient services.
In the CY 2008 OPPS/ASC proposed rule, we requested comments
regarding whether it would be appropriate for us to use the AMA
estimates of utilization for new codes in the estimation of the impact
of the final CY 2008 payments for hospitals. We received no comments on
this issue.
3. Estimated Impacts of This Final Rule With Comment Period on
Hospitals and CMHCs
Table 61 below shows the estimated impacts of this final rule with
comment period on hospitals. Historically, the first line of the impact
table, which estimates the change in payments to all hospitals, has
always included cancer and children's hospitals, which are held
harmless to their pre-BBA payment to cost ratio. This year, for the
first time, we are also including CMHCs in the first line that includes
all providers because we included CMHCs in our weight scaler estimate.
We are not showing the estimated impact of the changes on CMHCs alone
because CMHCs bill only one service under the OPPS, partial
hospitalization, and each CMHC can easily estimate the impact of the
changes by referencing payment for APC 0033 (Partial Hospitalization)
in Addendum A to this final rule with comment period. As discussed in
section II.B. of this final rule with comment period, the payment for
APC 0033 (Partial Hospitalization) for CY 2008 will decline by 13
percent compared to the payment for APC 0033 for CY 2007.
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. The
amounts attributable to this reclassification are incorporated into the
CY 2007 estimates but because section 508 expired for CY 2008 rates, no
additional payments under section 508 are considered for CY 2008 in
this impact analysis.
Table 61 shows the estimated redistribution of hospital and CMHC
payments among providers as a result of APC reconfiguration and
recalibration including the expansion of packaging; wage indices, and
continuation of the adjustment for rural SCHs and EACHs with extension
to brachytherapy sources in CY 2008; the estimated distribution of
increased payments in CY 2008 resulting from the combined impact of the
APC recalibration with the expansion of packaging, wage effects, the
rural SCH and EACH adjustment, and the market basket update to the
conversion factor; and, finally, estimated payments considering all
payments for CY 2008 relative to all payments for CY 2007, including
the impact of expiring wage provisions of section 508, changes in the
outlier threshold, and changes to the pass-through estimate. Because
updates to the conversion 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 for hospitals 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 would
depend on changes in volume, practice patterns, and the mix of services
billed between CY 2007 and CY 2008, which CMS cannot forecast.
Overall, the final OPPS rates for CY 2008 will have a positive
effect for providers paid under the OPPS,
[[Page 66910]]
resulting in a 3.6 percent increase in Medicare payments. Removing
cancer and children's hospitals because their payments are held
harmless to the pre-BBA ratio between payment and cost, and CMHCs,
suggests that changes will result in a 3.8 percent increase in Medicare
payments to all other hospitals, exclusive of transitional pass-through
payments.
To illustrate the impact of the final CY 2008 changes, our analysis
begins with a baseline simulation model that uses the final CY 2007
weights, the FY 2007 final post-reclassification IPPS wage indices, and
the final CY 2007 conversion factor. Column 2 in Table 61 shows the
independent effect of changes resulting from the reclassification of
services among APC groups, the recalibration of APC weights and the
changes to packaging that we adopted for this final rule with comment
period, based on 12 months of CY 2006 hospital OPPS claims data and
more recent cost report data. We modeled the effect of APC
recalibration and packaging changes for CY 2008 by varying only the
weights (the final CY 2007 weights versus the estimated CY 2008 weights
including expanded packaging in our baseline model) and calculating the
percent difference in payments. Column 2 also reflects the effect of
changes resulting from the APC reclassification and recalibration
changes and changes in multiple procedure discount patterns that occur
as a result of the changes to packaging. When services are packaged,
the resulting median costs at the HCPCS code level often change,
requiring migration of HCPCS codes to different APCs to address
violations of the 2 times rule (that is, to ensure that the HCPCS codes
within the APC remain homogeneous with regard to clinical and resource
characteristics). The placement of the HCPCS code in a new APC as a
result of the effect of the packaging approach often changes the APC
median cost. Furthermore, changing the cost of a service subject to the
multiple procedure discount policy, as well as packaging some services
previously subject to the multiple procedure discount policy, changes
the relative weight ranking of services on a claim subject to the
multiple procedure discount policy, significantly changing discounting
patterns in some cases.
Column 3 reflects the independent effects of updated wage indices,
including the new occupational mix data described in the FY 2008 IPPS
final rule, and the 7.1 percent rural adjustment for SCHs and EACHs
with extension to brachytherapy sources. The OPPS wage index for CY
2008 includes the budget neutrality adjustment for the rural floor, as
discussed in section II.D. of this final rule with comment period. We
modeled the independent effect of updating the wage index and the rural
adjustment by varying only the wage index, using the CY 2008 scaled
weights, and a CY 2007 conversion factor that included a budget
neutrality adjustment for changes in wage effects and the rural
adjustment between CY 2007 and CY 2008.
Column 4 demonstrates the combined ``budget neutral'' impact of APC
recalibration with the packaging policy (that is, Column 2), the wage
index update and the adjustment for rural SCHs and EACHs (that is,
Column 3), as well as the impact of updating the conversion factor with
the market basket update. We modeled the independent effect of the
budget neutrality adjustments and the market basket update by using the
weights and wage indices for each year, and using a CY 2007 conversion
factor that included the 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 CY 2008 policy on
each hospital group by including the effect of all the changes for CY
2008 (including the APC reconfiguration and recalibration with the
packaging changes shown in Column 2) and comparing them to all
estimated payments in CY 2007, including changes to the wage index
under section 508 of Public Law 108 173. Column 5 shows the combined
budget neutral effects of Columns 2 through 4, plus the impact of the
change to the fixed outlier threshold from $1,825 to $1,575, expiring
section 508 reclassification wage index increases, and the impact of
reducing the percentage of total payments dedicated to transitional
pass-through payments. We estimate that these cumulative changes
increase payments by 3.6 percent. We modeled the independent effect of
all changes in Column 5 using the final weights for CY 2007 and the
final weights for CY 2008. We used the final conversion factor for CY
2007 of $61.468 and the final CY 2008 conversion factor of $63.694.
Column 5 also contains simulated outlier payments for each year. We
used the charge inflation factor used in the FY 2008 IPPS final rule of
6.2 percent (1.062) to increase individual costs on the CY 2006 claims
to reflect CY 2007 dollars, and we used the most recent overall CCR in
the July 2007 Outpatient Provider-Specific File. Using the CY 2006
claims and a 6.2 percent charge inflation factor, we currently estimate
that outlier payments for CY 2007, using a multiple threshold of 1.75
and a fixed-dollar threshold of $1,825 would be approximately 0.73
percent of total payments. Outlier payments of 0.73 percent appear in
the CY 2007 comparison in Column 5. We used the same set of claims and
a charge inflation factor of 12.78 percent (1.1278) and the CCRs on the
July 2007 Outpatient Provider-Specific File, with an adjustment of
1.0027 to reflect relative changes in cost and charge inflation between
CY 2006 and CY 2008, to model the CY 2008 outliers at 1.0 percent of
total payments using a multiple threshold of 1.75 and a fixed dollar
threshold of $1,575.
Column 1: Total Number of Hospitals
The first line in Column 1 in Table 61 shows the total number of
providers (4,250), including cancer and children's hospitals and CMHCs
for which we were able to use CY 2006 hospital outpatient claims to
model CY 2007 and CY 2008 payments by classes of hospitals. We excluded
all hospitals for which we could not accurately estimate CY 2007 or CY
2008 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 Mariana Islands, American
Samoa, and the State of Maryland. This process is discussed in greater
detail in section II.A. of this final rule with comment period. 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 psychiatric hospitals, rehabilitation hospitals, and
LTCHs. We show the total number (3,984) of OPPS hospitals, excluding
the hold-harmless cancer and children's hospitals, and CMHCs, on the
second line of the table. We excluded cancer and children's hospitals
because section 1833(t)(7)(D) of the Act permanently holds harmless
cancer hospitals and children's hospitals to a proportion of their pre-
BBA payment relative to their pre-BBA costs and, therefore, we removed
them from our impact analyses. We excluded CMHCs because they only bill
one service under the OPPS, and thus they can easily determine the
impact of the changes.
Column 2: APC Changes Due to Reassignment, Recalibration and Packaging
This column shows the combined effects of reconfiguration,
recalibration, finalizing the packaging proposal and other policies
(for example, changes to
[[Page 66911]]
payment for brachytherapy sources and therapeutic
radiopharmaceuticals). In many cases, the redistribution created by the
reduction in the partial hospitalization payment offsets other
recalibration losses. Specifically, the reduction in partial
hospitalization payment is redistributed to hospitals and reflected in
the 0.2 percent increase for the 3,984 hospitals that remain after
excluding hospitals held harmless and CMHCs. Overall, these changes
will increase payments to urban hospitals by 0.3 percent. We estimate
that large urban hospitals will see an increase of 0.1 percent and
other urban hospitals will see a 0.4 percent increase in payments
attributable to all recalibration.
Overall, rural hospitals will show a modest 0.2 percent decrease as
a result of changes to the APC structure and the expansion of
packaging. Rural hospitals of all bed sizes will experience no change
or will experience decreases ranging from 0.1 to 0.6 percent. The
declines for rural hospitals for this final rule with public comment
period compared to the projected increases of 0.2 to 0.6 for rural
hospitals in the proposed rule is attributable to the changes in
packaging that we made as a result of public comments with regard to
observation and imaging supervision and interpretation services. The
proposed packaging of these services into payment for any service with
a status indicator of ``S,'' ``T,'' ``V,'' or ``X'' would have
increased OPPS payments for visits and other services provided in rural
hospitals. However, in response to public comments, we created
composite APCs for extended assessment and management involving
significant observation stays and we are packaging imaging supervision
and interpretation services only into services with a status indicator
of ``T.'' The services for which the median costs are increased as a
result of these final policies are performed more often in urban
hospitals than in rural hospitals, and this utilization is reflected in
the negative percents in Column 2.
Among teaching hospitals, the largest observed impacts resulting
from APC recalibration and the expansion of packaging include an
increase of 0.2 percent for major teaching hospitals and an increase of
0.4 percent for minor teaching hospitals.
Classifying hospitals by type of ownership suggests that
proprietary hospitals will see an increase of 0.3 percent while
governmental and voluntary hospitals will each see an increase of 0.2
percent.
We note also that both low volume urban and rural hospitals with
less than 5,000 lines and hospitals for which DSH payments are not
available will experience decreases of 3.7 to 5.5 percent as a result
of the decline in payment for partial hospitalization from CY 2007 to
CY 2008. These declines are somewhat moderated in Column 5 as a result
of the increased outlier payments that result from the lower payment
rates.
Column 3: New Wage Indices and the Effect of the Rural Adjustment
This column estimates the impact of applying the final IPPS FY 2008
wage indices for CY 2008, continuing the rural adjustment for CY 2008,
and extending the rural adjustment to include brachytherapy sources.
Overall, these changes will not change the payments to urban hospitals.
Overall, rural hospitals show a decrease of 0.1 percent.
Among teaching hospitals, the largest observed impacts resulting
from changes to the wage indices and the continuation of the rural
adjustment include a decrease of 0.1 percent for major teaching
hospitals and no change for minor teaching hospitals.
Classifying hospitals by type of ownership suggests that
proprietary hospitals will gain 0.1 percent and that governmental
hospitals and voluntary hospitals will each experience no change.
Column 4: All Budget Neutrality Changes and Market Basket Update
The addition of the market basket update of 3.3 percent alleviates
any negative impacts on payments for CY 2008 created by the budget
neutrality adjustments made in Columns 2 and 3, with the exception of
urban and rural hospitals with the lowest volume of services and
hospitals not paid under the IPPS, including psychiatric hospitals,
rehabilitation hospitals, and long term care hospitals (DSH not
available). In general, all hospitals see an increase of 3.5 percent,
attributable to the 3.3 percent market basket increase and the 0.2
percent increase in payment weight created by the reduction in payment
for partial hospitalization that is then redistributed to other
services.
Overall, these changes will increase payments to urban hospitals by
3.6 percent. We estimate that large urban hospitals will see an
increase of 3.5 percent and other urban hospitals will see a 3.7
percent increase. In contrast, small urban hospitals that bill fewer
than 5,000 lines per year will experience a decrease in payment of 0.4
percent, largely as a result of the decrease in payment for partial
hospitalization and mental health services appearing in Column 2.
Overall, rural hospitals show a 3.0 percent increase as a result of
the market basket update. Rural hospitals that bill less than 5,000
lines will see a 1.8 percent decrease, also as a result of decreases in
payment for partial hospitalization appearing in Column 2. Rural
hospitals that bill more than 5,000 lines will experience increases of
2.8 to 3.5 percent.
Among teaching hospitals, the observed impacts resulting from the
market basket update include an increase of 3.6 percent for minor
teaching hospitals and an increase of 3.3 percent for major teaching
hospitals.
Classifying hospitals by type of ownership suggests that
proprietary hospitals will increase 3.8 percent and governmental and
voluntary hospitals will experience an increase of 3.5 percent.
Column 5: All Changes for CY 2008
Column 5 compares all changes for CY 2008 to final payment for CY
2007 and includes the expired section 508 reclassification wage
indices, the change in the outlier threshold, and the difference in
pass through estimates which are not included in the combined
percentages shown in Column 4. Overall, we estimate that providers will
see an increase of 3.6 percent under this final rule with comment
period in CY 2008 relative to total spending in CY 2007. The 3.6
percent increase for all providers in Column 5, which is rounded from
3.56 percent, reflects the 3.3 percent market basket increase, plus
0.12 percent for the change in the pass-through estimate between CY
2007 and CY 2008, plus 0.27 percent for the difference in estimated
outlier payments between CY 2007 (0.73 percent) and CY 2008 (1.0
percent), less 0.13 percent for the expired section 508 wage payments.
When we exclude cancer and children's hospitals (which are held
harmless to their pre-OPPS costs), and CMHCs, the gain becomes 3.8
percent.
The combined effect of all changes for CY 2008 will increase
payments to urban hospitals by 3.9 percent. We estimate that large
urban hospitals will see a 3.9 percent increase, while ``other'' urban
hospitals will experience an increase of 3.8 percent. Urban hospitals
that bill less than 5,000 lines will experience an increase of 0.8
percent, up from the 0.4 percent decrease in Column 4 due to increases
in outlier payments for partial hospitalization.
Overall, rural hospitals will show a 3.1 percent increase as a
result of the combined effects of all changes for CY 2008. Rural
hospitals will experience a
[[Page 66912]]
lower increase than the 3.8 percent overall hospital increase as a
result of the combined effects of the changes to the packaging policies
that were made in response to public comments and the expiration of the
section 508 reclassification wage indices. Rural hospitals that bill
less than 5,000 lines experience a decrease of 1.5 percent, which is
less than the 1.8 percent decrease in Column 4 due to an increase in
outlier payments for partial hospitalization. All rural hospitals that
bill greater than 5,000 lines experience increases ranging from 2.9
percent to 3.7 percent.
Among teaching hospitals, the largest observed impacts resulting
from the combined effects of all changes include an increase of 3.8
percent for major teaching hospitals and minor teaching hospitals.
Classifying hospitals by type of ownership suggests that
proprietary hospitals will gain 4.1 percent, governmental hospitals
will experience an increase of 3.9 percent, and voluntary hospitals
will experience an increase of 3.7 percent.
Table 61.--Impact of Changes for CY 2008 Hospital Outpatient Prospective Payment System
----------------------------------------------------------------------------------------------------------------
Combined
New wage (cols 2,3)
Number of APC changes index and with market All changes
hospitals rural basket
adjustment update
(1) (2) (3) (4) (5)
----------------------------------------------------------------------------------------------------------------
ALL PROVIDERS \*\.............................. 4,250 0.0 0.0 3.3 3.6
ALL HOSPITALS (excludes hospitals held harmless 3,984 0.2 0.0 3.5 3.8
and CMHCs)....................................
URBAN HOSPITALS................................ 2,978 0.3 0.0 3.6 3.9
Large urban (GT 1 MILL.)................... 1,620 0.1 0.1 3.5 3.9
Other urban (LE 1 MILL.)................... 1,358 0.4 0.0 3.7 3.8
RURAL HOSPITALS................................ 1,006 -0.2 -0.1 3.0 3.1
Sole community............................. 407 -0.2 0.1 3.1 3.0
Other rural................................ 599 -0.2 -0.3 2.8 3.1
BEDS (URBAN):
0-99 Beds.................................. 1,002 0.3 0.1 3.7 3.9
100-199 Beds............................... 919 0.1 0.1 3.5 3.6
200-299 Beds............................... 476 0.4 0.0 3.7 4.0
300-499 Beds............................... 399 0.3 0.1 3.7 4.0
500 + Beds................................. 182 0.3 -0.1 3.5 3.9
BEDS (RURAL):
0-49 Beds \***\............................ 350 -0.1 -0.2 3.1 3.3
50-100 Beds \***\.......................... 391 -0.2 0.0 3.1 3.3
101-149 Beds............................... 156 0.0 -0.1 3.2 3.4
150-199 Beds............................... 66 -0.2 -0.7 2.4 2.5
200 + Beds................................. 43 -0.6 0.1 2.8 2.6
VOLUME (URBAN):
LT 5,000 Lines............................. 616 -3.7 0.0 -0.4 0.8
5,000-10,999 Lines......................... 174 0.2 0.1 3.6 4.0
11,000-20,999 Lines........................ 247 0.6 0.1 4.0 4.4
21,000-42,999 Lines........................ 526 0.5 0.2 4.0 4.2
GT 42,999 Lines............................ 1,415 0.3 0.0 3.6 3.9
VOLUME (RURAL):
LT 5,000 Lines............................. 83 -4.8 -0.3 -1.8 -1.5
5,000-10,999 Lines......................... 92 -0.1 -0.1 3.1 3.6
11,000-20,999 Lines........................ 189 0.1 -0.1 3.3 3.4
21,000-42,999 Lines........................ 314 0.1 0.1 3.5 3.7
GT 42,999 Lines............................ 328 -0.3 -0.2 2.8 2.9
REGION (URBAN):
New England................................ 157 -0.3 0.2 3.2 3.3
Middle Atlantic............................ 378 0.2 -0.1 3.4 3.5
South Atlantic............................. 462 0.2 -0.1 3.5 3.8
East North Cent............................ 469 0.4 -0.1 3.6 3.7
East South Cent............................ 194 0.4 -0.3 3.5 3.8
West North Cent............................ 186 0.4 0.1 3.8 4.1
West South Cent............................ 493 0.6 -0.4 3.5 3.8
Mountain................................... 189 0.7 0.0 4.0 4.4
Pacific.................................... 398 -0.1 0.9 4.2 4.7
Puerto Rico................................ 52 1.0 0.0 4.3 4.7
REGION (RURAL):
New England................................ 25 -0.5 -0.6 2.2 2.6
Middle Atlantic............................ 70 -0.7 0.0 2.7 2.9
South Atlantic............................. 172 -0.3 -0.2 2.7 3.0
East North Cent............................ 129 -0.1 -0.1 3.2 3.0
East South Cent............................ 177 -0.1 -0.4 2.8 3.0
West North Cent............................ 115 -0.2 0.0 3.1 3.1
West South Cent............................ 205 -0.1 -0.8 2.4 2.7
Mountain................................... 76 0.0 0.3 3.6 3.8
Pacific.................................... 37 0.0 1.9 5.2 5.1
TEACHING STATUS:
Non-teaching............................... 2,956 0.1 0.1 3.5 3.7
[[Page 66913]]
Minor...................................... 748 0.4 0.0 3.6 3.8
Major...................................... 280 0.2 -0.1 3.3 3.8
DSH PATIENT PERCENT:
0.......................................... 5 4.4 -0.5 7.3 7.5
GT 0-0.10.................................. 416 0.3 0.1 3.6 3.9
0.10-0.16.................................. 451 0.3 -0.1 3.4 3.4
0.16-0.23.................................. 796 0.3 0.0 3.6 3.7
0.23-0.35.................................. 948 0.2 0.0 3.4 3.7
GE 0.35.................................... 754 0.3 0.1 3.7 4.2
DSH not available \**\..................... 614 -5.5 0.4 -1.9 -1.3
URBAN TEACHING/DSH:
Teaching & DSH............................. 920 0.3 -0.1 3.6 3.9
No teaching/DSH............................ 1,472 0.3 0.1 3.7 4.0
No teaching/no DSH......................... 5 4.4 -0.5 7.3 7.5
DSH not available \**\..................... 581 -5.5 0.4 -1.8 -1.3
TYPE OF OWNERSHIP:
Voluntary.................................. 2,141 0.2 0.0 3.5 3.7
Proprietary................................ 1,255 0.3 0.1 3.8 4.1
Government................................. 588 0.2 0.0 3.5 3.9
----------------------------------------------------------------------------------------------------------------
Column (1) shows total hospitals.
Column (2) shows the impact of changes resulting from the reclassification of HCPCS codes among APC groups and
the recalibration of APC weights based on 2006 hospital claims data.
Column (3) shows the budget neutral impact of updating the wage index and rural adjustment by applying the FY
2008 hospital inpatient wage index and extended to rural adjustment to brachytherapy sources.
Column (4) shows the impact of all budget neutrality adjustments and the addition of the market basket update.
Column (5) shows the additional adjustments to the conversion factor resulting from a change in the pass-through
estimate, and adds outlier payments. The change in outlier payments reflects a decrease in the fixed dollar
threshold resulting from updated claim, CCR, and inflation estimates. This column also shows the impact of the
expired section 508 wage reclassification, which ended on September 30, 2007.
\*\ These 4,250 providers include children and cancer hospitals, which are held harmless to pre-BBA payments,
and CMHCs.
\**\ Complete DSH numbers are not available for providers that are not paid under IPPS, including
rehabilitation, psychiatric, and long-term care hospitals.
\***\ Section 1833(t)(7)(D) of the Act specifies that rural hospitals with 100 or fewer beds (that are not also
SCHs) receive additional payment for covered hospital outpatient services furnished during CY 2008 for which
the prospective payment system amount is less than the pre-BBA amount. The amount of payment is increased by
85 percent of the difference for CY 2008.
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 will
increase for services for which the OPPS payments will rise and will
decrease for services for which the OPPS payments will fall. For
example, for an electrocardiogram (APC 0099), the minimum unadjusted
copayment in CY 2007 was $4.66. In this final rule with comment period,
the minimum unadjusted copayment for APC 0099 is $4.96 because the OPPS
payment for the service will increase under this final rule with
comment period. In another example, for a service assigned to Level IV
Needle Biopsy/Aspiration Except Bone Marrow (APC 0037) in the CY 2007
OPPS, the national unadjusted copayment was $228.76, and the minimum
unadjusted copayment was $126.20. In this final rule with comment
period, the national unadjusted copayment for APC 0037 is $228.76, the
same national unadjusted copayment in effect for CY 2007. The minimum
unadjusted copayment for APC 0037 is $172.95, or 20 percent of the
payment for APC 0037. The minimum unadjusted copayment will rise
because the payment rate for APC 0037 will rise. In all cases, the
statute limits beneficiary liability for copayment for a service to the
inpatient hospital deductible for the applicable year. For CY 2008, the
inpatient deductible is $1,024.
In order to better understand the impact of changes in copayment on
beneficiaries, we modeled the percent change in total copayment
liability using CY 2006 claims. We estimate, using the claims of the
4,250 hospitals and CMHCs on which our modeling is based, that total
beneficiary liability for copayments will decline as an overall
percentage of total payments from 26.5 percent in CY 2007 to 25.1
percent in CY 2008. This estimated decline in beneficiary liability is
a consequence of the APC recalibration and reconfiguration we are
making for CY 2008.
With respect to partial hospitalization, the copayment in CY 2007
of $46.95 will decline to $41.03 under this final rule with comment
period as a result of the decline in the per diem payment for partial
hospitalization from $234.73 in CY 2007 to $205.16 for CY 2008.
5. Conclusion
The changes in this final rule with comment period will affect all
classes of hospitals. Some classes of hospitals experience significant
gains and others less significant gains, but almost all classes of
hospitals will experience positive updates in OPPS payments in CY 2008.
Table 61 demonstrates the estimated distributional impact of the OPPS
budget neutrality requirements and an additional 3.6 percent increase
in payments for CY 2008, after considering all changes to APC
reconfiguration and recalibration, including those resulting from the
expansion of packaging and the payment for brachytherapy sources on a
prospective payment basis, as well as
[[Page 66914]]
the market basket increase, and the estimated cost of outliers and
changes to the pass through estimate. 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 62, we have
prepared an accounting statement showing the CY 2008 estimated hospital
OPPS incurred benefit impact associated with the CY 2008 outpatient
hospital market basket update shown in this final rule with comment
period, based on the Mid-Session Review of the FY 2008 President's
Budget baseline. All estimated impacts are classified as transfers.
Table 62.--Accounting Statement: CY 2008 Estimated Hospital OPPS
Incurred Benefit Impact Associated With the CY 2008 Hospital Outpatient
Market Basket Update
[In billions]
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers....... $0.9.
From Whom To Whom?................... Federal Government to outpatient
hospitals and other providers
who receive payment under the
hospital OPPS.
------------------------------------------------------------------------
C. Effects of ASC Payment System Changes in This Final Rule With
Comment Period
On August 2, 2007, we published in the Federal Register the final
rule for the revised ASC payment system, effective January 1, 2008 (72
FR 42470). In that final rule for the revised ASC payment system, we
adopted the methodologies we will use to set payment rates for ASC
services furnished in association with covered surgical procedures and
covered ancillary procedures beginning January 1, 2008, and established
that the OPPS relative payment weights will be used as the basis for
the payment of most covered surgical procedures and covered ancillary
services under the revised ASC payment system.
In the August 2, 2007 revised ASC payment system final rule, we
established that we will update the ASC payment system annually as part
of the OPPS rulemaking cycle. As part of the annual OPPS rulemaking
cycle, we indicated we will update the lists of ASC covered surgical
procedures and covered ancillary services, as well as their payment
rates. Such an update is very important because the OPPS relative
payment weights will be used as the basis for the payment of most
covered surgical procedures and covered ancillary services under the
revised ASC payment system. This joint update process will ensure that
the ASC updates occur in a regular, predictable, and timely manner, and
that the ASC payment rates immediately reflect the updated OPPS
relative payment weights.
In the CY 2008 OPPS/ASC proposed rule, we proposed to update the
revised ASC payment system for CY 2008 to reflect the CY 2008 OPPS
relative payment weights and rates, as well as update the lists of
covered surgical and covered ancillary services (72 FR 42778). We also
proposed to revise the regulations to make practice expense payment to
physicians who perform noncovered ASC procedures in ASCs based on the
MPFS facility PE RVUs (72 FR 42791) and to exclude covered ancillary
radiology services and covered ancillary drugs and biologicals from the
categories of DHS that are subject to the physician self-referral
prohibition (72 FR 42792). We are finalizing those proposals in this
final rule with comment period.
The revised Medicare ASC payment system that we are implementing
beginning January 1, 2008, could have a far-reaching effect on the
provision of outpatient surgical services for a number of years to come
for several reasons. First, the list of procedures that will be
eligible for payment under the revised ASC payment system is greatly
expanded from the list of surgical procedures eligible for payment
under the ASC payment system in CY 2007 and earlier years. In addition,
we are moving from a limited fee schedule based on nine disparate
payment groups to a payment system incorporating relative payment
weights for groups of procedures with similar clinical and resource
characteristics, that is, the APC groups that are the unit of payment
in the OPPS.
Implementation by January 1, 2008 of a revised ASC payment system
designed to result in budget neutrality is mandated by section 626 of
Public Law 108-173. To set ASC payment rates for CY 2008 under the
revised payment system, we are multiplying ASC relative payment weights
for surgical procedures by an ASC conversion factor that we calculated
to result in the same amount of aggregate Medicare expenditures in CY
2008 as we estimate would have been made if the revised payment system
were not implemented (72 FR 42796).
The effects of the expanded number and types of procedures for
which an ASC payment may be made and other policy changes that affect
the revised payment system, combined with significant changes in
payment rates for covered surgical procedures, will vary across ASCs,
depending on whether or not the ASC limits its services to those in a
particular surgical specialty area, the volume of specific services
provided by the ASC, the extent to which ASCs will offer different
services, and the percentage of its patients that are Medicare
beneficiaries.
In the August 2, 2007 OPPS/ASC proposed rule (42 FR 42628), we
estimated the CY 2008 ASC payment rates, budget neutrality adjustment
factor, and impacts using the proposed CY 2008 OPPS relative payment
weights and update factor for CY 2008, the proposed CY 2008 MPFS PE
RVUs, and partial CY 2006 utilization data projected forward to CY
2008. In this final rule with comment period, we are establishing the
final CY 2008 ASC payment rates and budget neutrality adjustment in
accordance with the methodology for calculating budget neutrality
established in the August 2, 2007 revised ASC payment system final rule
and based on the final CY 2008 OPPS payment weights, the final CY 2008
MPFS PE RVUs, and updated CY 2006 utilization data projected forward to
CY 2008.
Our final methodology for calculating the budget neutrality
adjustment established in the August 2, 2007 revised ASC payment system
final rule considered not only the effects of the new payment rates to
be implemented under the revised ASC payment system, but also the
estimated net effect of migration of new ASC procedures across
ambulatory care settings. Both the
[[Page 66915]]
proposed budget neutrality adjustment presented in the August 2, 2007
OPPS/ASC proposed rule and the budget neutrality adjustment in this
final rule with comment period are based on that methodology, which
takes into account projected migration. In the final model, we assume
that over the first 2 years of the revised payment system,
approximately 25 percent of the HOPD volume of new ASC procedures will
migrate from the HOPD service setting to ASCs, and that over the 4-year
transition period, approximately 15 percent of the physicians' office
volume of new ASC procedures will migrate to ASCs.
We estimate that the revised ASC payment system will result in
neither savings nor costs to the Medicare program in CY 2008. That is,
because it is designed to be budget neutral, in CY 2008, the revised
ASC payment system will neither increase nor decrease expenditures
under Part B of Medicare. We further estimate that beneficiaries will
save approximately $20 million under the revised ASC payment system in
CY 2008, because ASC payment rates will, in most cases, be lower than
OPPS payment rates for the same services and because, except for
screening flexible sigmoidoscopy and screening colonoscopy procedures,
beneficiary coinsurance for ASC services is 20 percent rather than 20
to 40 percent as is the case under the OPPS. (The only possible
instance in which an ASC coinsurance amount could exceed the OPPS
copayment amount will be when the coinsurance amount for a procedure
under the revised ASC payment system exceeds the hospital inpatient
deductible. Section 1833(t)(8)(C)(i) of the Act provides that the
copayment amount for a procedure paid under the OPPS cannot exceed the
inpatient deductible established for the year in which the procedure is
performed, but there is no such requirement related to the ASC
coinsurance amount.) Beneficiary coinsurance for services migrating
from physicians' offices to ASCs may decrease or increase under the
revised ASC payment system, depending on the particular service and
whether the Medicare payment to the physician for providing that
service in his or her office is higher or lower than the sum of the
Medicare payment to the ASC for providing the facility portion of that
service and the Medicare payment to the physician for providing that
service in a facility (non-office) setting. As noted previously, the
net effect of the revised ASC payment system on beneficiary
coinsurance, taking into account the migration of services from HOPDs
and physicians' offices, is estimated to be $20 million in beneficiary
savings in CY 2008.
1. Alternatives Considered
Alternatives to the changes we are making and the reasons that we
have chosen the 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. Office-Based Procedures
According to our final policy for the revised ASC payment system,
we designate as office-based those procedures that are added to the ASC
list of covered surgical procedures in CY 2008 or later years and that
we determine are predominantly performed in physicians' offices based
on consideration of the most recent available volume and utilization
data for each individual procedure code and/or, if appropriate, the
clinical characteristics, utilization, and volume of related codes. We
establish payment for procedures designated as office-based at the
lesser of the MPFS nonfacility PE RVU amount or the ASC rate developed
according to the standard methodology of the revised ASC payment
system. In the August 2, 2007 OPPS/ASC proposed rule, we proposed to
designate 19 additional procedures as office-based, based on our
evaluation of the most recent available CY 2006 volume and utilization
data for each individual procedure code and/or related codes. In
developing this final rule with comment period, we reviewed the newly
available CY 2006 utilization data for all the surgical procedures we
proposed to designate as office-based. Based on that review, we are
designating 18 additional procedures as office-based for CY 2008. We
considered two alternatives in developing this policy.
The first alternative we considered was to make no change to the
current policy for these 19 procedures. This would mean that we would
continue to pay these procedures at the standard ASC payment rate
developed according to the standard methodology of the revised ASC
payment system. We did not select this alternative because our analysis
of data for these services and related procedures indicated that 18 of
the procedures we proposed to designate as office-based could be
considered to be predominantly performed in physicians' offices.
Consistent with our final policy adopted in the August 2, 2007 revised
ASC payment system final rule (72 FR 42509), we were concerned that if
these services were not designated as office-based, it could create
financial incentives for the procedures to shift from physicians'
offices to ASCs for reasons unrelated to the most appropriate setting
for surgical care.
The second alternative we considered, and the alternative we
selected, is to designate 18 additional procedures as office-based for
CY 2008. We selected this alternative because our claims data indicate
that these procedures could be considered to be predominantly performed
in physicians' offices. We believe that designating these procedures as
office-based, which results in the ASC payment rate for these
procedures being capped at the physician's office rate (that is, the
MPFS nonfacility practice PE RVU amount), if applicable, is an
appropriate step to ensure that Medicare payment policy does not create
financial incentives for such procedures to shift unnecessarily from
physicians' offices to ASCs, consistent with our final policy adopted
in the August 2, 2007 revised ASC payment system final rule.
b. Partial Device Credits
We are reducing the ASC payment by one half of the device offset
amount for certain surgical procedures into which the device cost is
packaged, when an ASC receives a partial credit toward replacement of
specific implantable devices. This partial payment reduction will apply
when the amount of the device credit is greater than or equal to 50
percent of the cost of the new replacement device being implanted.
Under this policy, both the Medicare payment to the ASC and the
beneficiary coinsurance liability will be reduced when an ASC receives
a partial device credit. This policy is an extension of the policy
established in the August 2, 2007 revised ASC payment system final
rule, which reduces the ASC payment by the full device offset amount
for certain devices when the ASC receives a replacement device without
cost or receives a credit for the full cost of the device being
replaced. The final partial device credit policy for ASCs mirrors the
final partial device credit for the OPPS in this final rule with
comment period. We considered several alternatives in developing this
partial device credit policy for CY 2008.
The first alternative we considered was to make no change to the
current policy. Under this alternative, Medicare and the beneficiary
would continue to pay the ASC the full payment rate for the device
implantation procedure even if the ASC received a substantial credit
towards the cost of the replacement
[[Page 66916]]
device. The ASC payment for the device implantation procedure is based
on the OPPS relative weight for the procedure, which is calculated
using only OPPS claims for which the full cost of a device is billed.
We did not select this alternative because we believe that, as long as
the ASC payment amount is established based on an OPPS relative weight
that is calculated using only claims that reflect the full cost of the
device when there is no credit, there should be a reduction in the
Medicare payment amount when the ASC receives a substantial credit
toward the cost of the replacement device. Similarly, we believe that
the beneficiary cost sharing should be based on an amount that also
reflects the device credit.
The second alternative we considered was to extend the current no
cost/full credit reduction policy to cases of partial credit, without
change. This would reduce the payment in all cases in which the ASC
received a credit by the full offset amount for the device implantation
procedure, that is, by 100 percent of the estimated device cost
included in the procedure payment rate. We did not select this
alternative because we did not believe it was appropriate to reduce the
payment to the ASC by the full cost of a device if the ASC only
received a partial credit, and not a full credit, towards the cost of
the device.
The third alternative, which we are adopting in this final rule
with comment period, is to reduce the ASC procedure payment by 50
percent of the offset amount (that will be applied if the ASC received
full credit) in cases in which the ASC receives a partial credit
greater than or equal to 50 percent of the cost of the new replacement
device being implanted. This is consistent with the final CY 2008 OPPS
policy described in detail in section IV.A.3. of this final rule with
comment period. We will reduce the ASC payment for the specific
procedure to implant the device by one-half of the device offset that
would be applied if a replacement device were provided at no cost or
with full credit, if the credit is 50 percent or more of the new
replacement device cost, rather than the proposed 20 percent. We
believe that payment policies across the OPPS and the ASC payment
system should align whenever possible and appropriate, as is true in
this case. Moreover, we are requiring the ASC to report a new modifier
when the ASC receives a partial credit that is greater than or equal to
50 percent of the cost of the device being replaced. We are selecting
this alternative because we believe that this approach provides an
appropriate and equitable payment to the ASC from Medicare and will
reduce the beneficiary's cost sharing for the service.
c. Payment to Physicians for Services Not on the ASC List of Covered
Surgical Procedures
Under current policy, when physicians perform surgical procedures
in ASCs that are included on the ASC list of covered surgical
procedures, they are paid under the MPFS for the PE component using the
facility PE RVUs. When physicians perform surgical procedures in ASCs
that are not included on the ASC list of covered surgical procedures
and for which Medicare does not allow facility payments to ASCs,
physicians currently are paid for the PE component at the higher
nonfacility rate (unless a nonfacility rate does not exist, in which
case Medicare pays the facility rate). In this final rule with comment
period, we are providing that regardless of whether a procedure is on
the ASC list of covered surgical procedures, a physician performing
that procedure in an ASC will receive payment based on the facility PE
RVUs and excluding the technical component (TC) payment, if applicable.
We considered two alternatives in developing this policy.
The first alternative we considered was to make no change to the
current policy concerning physician payment for services performed in
ASCs that are not on the ASC list of covered surgical procedures. Under
current policy, the physician is paid the higher nonfacility PE amount
for performing a service in an ASC that is not on the ASC list of
covered surgical procedures (unless a nonfacility rate does not exist
in which case Medicare pays the facility PE rate). We adopted a final
policy to identify and exclude from ASC payment only those procedures
that could pose a significant risk to beneficiary safety or would be
expected to require an overnight stay. Because the excluded procedures
have been specifically identified by CMS as procedures that are unsafe
for Medicare beneficiaries in ASCs because they could pose a
significant risk to beneficiary safety or would be expected to require
an overnight stay, we do not believe it would be appropriate to provide
payment based on the higher nonfacility PE RVUs to physicians who
furnish them. Consequently, we did not select this alternative.
The second alternative that we considered, and that we selected,
was to provide payment to physicians for performing procedures in ASCs
based on the facility PE RVUs and excluding the TC payment, if
applicable, regardless of whether a procedure is on the ASC list of
covered surgical procedures. We selected this alternative for several
reasons. We believe ASCs are facilities that are similar, insofar as
the delivery of surgical and related nonsurgical services, to HOPDs.
Specifically, when services are provided in ASCs, the ASC, not the
physician, bears responsibility for the facility costs associated with
the service. This situation parallels the hospital facility resource
responsibility for hospital outpatient services. Therefore, we believe
it would be more appropriate for physicians to be paid for all services
furnished in ASCs just as they would be paid for all services furnished
in the hospital outpatient setting. In addition, because we have
adopted a final policy for the revised ASC payment system that
identifies and excludes from ASC payment only those procedures that
could pose a significant risk to beneficiary safety or would be
expected to require an overnight stay, we believe that it would be
incongruous with the revised ASC payment system methodology to continue
to pay the higher nonfacility rate to physicians who furnish excluded
ASC procedures.
2. Limitations of Our Analysis
Presented here are the projected effects of the policy and
statutory changes that will be effective for CY 2008 on aggregate ASC
utilization and Medicare payments. One limitation is our lack of
information on ASC resource use. ASCs are not required to file Medicare
cost reports and, therefore, we do not have cost information to
evaluate whether or not the payments for ASC services coincide with the
resources required by ASCs to provide those services. A second
limitation of our analysis is our inability to predict changes in
service mix between CY 2006 and CY 2008 with precision. The aggregated
impact tables below are based upon a methodology that assumes no
changes in service mix with respect to the CY 2006 ASC data used for
this final rule with comment period. We believe that the net effect on
Medicare expenditures resulting from changes in service mix for current
ASC covered surgical procedures will be negligible in the aggregate.
Such changes may have differential effects across surgical specialties
as ASCs adjust to payment rates. However, we are unable to accurately
project such changes at a disaggregated level. Clearly, individual ASCs
will experience changes in payment that differ from the aggregated
estimated changes presented below.
[[Page 66917]]
3. Estimated Effects of This Final Rule With Comment Period on ASCs
a. Payment to ASCs
Some ASCs are multispecialty facilities that perform the gamut of
surgical procedures, from excision of lesions to hernia repair to
cataract extraction; others focus on a single specialty and perform
only a limited range of surgical procedures, such as eye, digestive
system, or orthopedic procedures. The combined effect on an individual
ASC of the CY 2008 revised payment system and the expanded ASC list of
covered surgical procedures will depend on a number of factors,
including, but not limited to, the mix of services the ASC provides,
the volume of specific services provided by the ASC, the percentage of
its patients who are Medicare beneficiaries, and the extent to which an
ASC will choose to provide different services. The following discussion
presents tables that provide estimates of the impact of the revised ASC
payment system on Medicare payments to ASCs for current ASC services,
assuming the same mix of services as reflected in our CY 2006 claims
data. Table 63 depicts the aggregate percent change in payment by
surgical specialty group and Table 64 shows a comparison of payment for
procedures that we estimate would receive the most Medicare payment in
CY 2008 under the current payment system.
In section XVI.C.1.c.(5) of this final rule with comment period, we
reiterate the transition of 4 years under the revised ASC payment
system, where payments for most surgical procedures will be made using
a blend of the rates based on the CY 2007 ASC payment rate and the
revised ASC payment rate. In CY 2008, we will pay ASCs using a 75/25
blend, in which payment will be calculated by adding 75 percent of the
CY 2007 ASC rate for a surgical procedure on the CY 2007 ASC list of
covered surgical procedures and 25 percent of the CY 2008 revised ASC
rate for the same procedure. For CYs 2009 and 2010, we will transition
the blend first to 50/50 and then to a 25/75 blend of the CY 2007 ASC
rate and the revised ASC payment rate. Beginning in CY 2011, we will
pay ASCs for covered surgical procedures on the CY 2007 ASC list at the
fully implemented revised ASC payment rates. We will not transition
payment for procedures that were not included on the ASC list of
covered surgical procedures in CY 2007; we will pay for these
procedures at the fully implemented ASC rate, beginning in CY 2008.
Table 63 shows the effects on aggregate Medicare payments under the
revised ASC payment system by surgical specialty group. We have
aggregated the surgical HCPCS codes by specialty group and estimated
the effect on aggregated payment for surgical specialty groups,
considering separately the CY 2008 transitional rate and the fully
implemented revised ASC payment rate discussed above. The groups are
sorted for display in descending order by estimated Medicare program
payment to ASCs for CY 2008 in the absence of the revised ASC payment
system. The following is an explanation of the information presented in
Table 63.
Column 1--Surgical Specialty Group indicates the surgical
specialties into which ASC procedures are grouped. We used the CPT code
range definitions and Level II HCPCS codes and Category III CPT codes,
as appropriate, to account for all surgical procedures to which the
Medicare program payments are attributed.
Column 2--Estimated CY 2008 ASC Payments in the absence of
the revised ASC payment system were calculated by multiplying the CY
2007 ASC payment rate by CY 2008 ASC utilization (which is based on CY
2006 ASC utilization multiplied by a factor of 1.176 to take into
account expected volume growth with volume adjustment, as appropriate,
for the multiple procedure discount). The resulting amount was then
multiplied by 0.8 to estimate the Medicare program's share of the total
payments to the ASC. The estimated CY 2008 payment amounts are
expressed in millions of dollars.
Column 3--Estimated CY 2008 Percent Change with Transition
(75/25 Blend) is the aggregate percentage increase or decrease in
Medicare program payment to ASCs for each surgical specialty group that
is attributable to changes in the ASC payment rates for CY 2008 under
the 75/25 blend of the CY 2007 ASC payment rate and the CY 2008 revised
ASC payment rate.
Column 4--Estimated CY 2008 Percent Change without
Transition (Fully Implemented) is the aggregate percentage increase or
decrease in Medicare program payment to ASCs for each surgical
specialty group that is attributable to changes in the ASC payment
rates for CY 2008 if there were no transition period to the revised
payment rates. The percentages appearing in Column 4 are presented as
comparisons to the percentage changes under the transition policy in
column 3 and do not depict the impact of the fully implemented policy
in 2011.
As seen in Table 63, for all but digestive system procedures, if an
ASC offers the same mix of services in CY 2008 that is reflected in our
national CY 2006 claims data, Medicare payments to the ASC for services
in that surgical specialty group are expected to increase under the
revised payment system. If the revised payment system was fully
implemented in CY 2008, we expect all but digestive system procedures
and nervous system procedures to receive greater Medicare payment. In
addition to the effects on Medicare payments for current ASC procedures
shown in Table 63, it is important to note that estimated CY 2008
payments to ASCs are estimated to increase by more than $240 million in
CY 2008 due to projected migration of new ASC services from HOPDs and
physicians' offices to ASC. This increased spending in ASCs is
projected to be fully offset by savings from reduced spending in HOPDs
and physicians' offices due to service migration.
Table 63.--Estimated CY 2008 Impact of the Revised ASC Payment System on Estimated Aggregate CY 2008 Medicare
Program Payments Under the 75/25 Transition Blend and Without a Transition, by Surgical Specialty Group
----------------------------------------------------------------------------------------------------------------
Estimated CY
Estimated CY Estimated CY 2008 percent
2008 ASC 2008 percent change without
Surgical specialty group payments (in change with transition
millions) transition (75/ (fully
25 Blend) implemented)
(1) (2) (3) (4)
----------------------------------------------------------------------------------------------------------------
Eye and ocular adnexa........................................... $1,247 2 3
[[Page 66918]]
Digestive system................................................ 708 -4 -16
Nervous system.................................................. 260 3 -4
Musculoskeletal system.......................................... 165 24 94
Integumentary system............................................ 75 8 32
Genitourinary system............................................ 74 11 43
Respiratory system.............................................. 18 16 64
Cardiovascular system........................................... 8 24 94
Auditory system................................................. 4 23 80
Hemic and lymphatic systems..................................... 2 31 124
Other systems................................................... 0.1 27 108
----------------------------------------------------------------------------------------------------------------
Table 64 below shows the estimated impact of the revised payment
system on aggregate ASC payments for selected procedures during the
first year of implementation (CY 2008) with and without the
transitional blended rate. The table displays 30 of the procedures
receiving the most Medicare estimated CY 2008 ASC payments under the
existing Medicare payment system. The HCPCS codes are sorted in
descending order by estimated program payment.
Column 1--HCPCS code
Column 2--Short Descriptor of the HCPCS code
Column 3--Estimated CY 2008 ASC Payments in the absence of
the revised payment system were calculated by multiplying the CY 2007
ASC payment rate by CY 2008 ASC utilization (which is based on CY 2006
ASC utilization multiplied by a factor of 1.176 to take into account
expected volume growth with volume adjustment, as appropriate, for the
multiple procedure discount). The resulting amount was then multiplied
by 0.8 to estimate the Medicare program's share of the total payments
to the ASC. The estimated CY 2008 payment amounts are expressed in
millions of dollars.
Column 4--CY 2008 Percent Change with Transition (75/25
Blend) reflects the percent differences between the estimated ASC
payment rates for CY 2008 under the current system and the payment
rates for CY 2008 under the revised system, incorporating a 75/25 blend
of the estimated ASC payment using the CY 2007 ASC payment rate and the
CY 2008 revised ASC payment rate.
Column 5--CY 2008 Percent Change without Transition (Fully
Implemented) reflects the percent differences between the estimated ASC
payment rates for CY 2008 under the current system and the estimated
payment rates for CY 2008 under the revised payment system if there
were no transition period to the revised payment rates. The percentages
appearing in Column 5 are presented as a comparison to the percentage
changes under the transition policy in Column 4 and do not depict the
impact of the fully implemented policy in 2011.
Table 64.--Estimated CY 2008 Impact of Revised ASC Payment System on Aggregate Payments for Procedures With the
Most Medicare Estimated CY 2008 Payments Under the Current System
----------------------------------------------------------------------------------------------------------------
Estimated CY
Estimated Estimated 2008 percent
CY 2008 ASC CY 2008 changes
HCPCS code Short descriptor payments percent without
(in change (75/ transition
millions) 25 blend) (fully
implemented)
----------------------------------------------------------------------------------------------------------------
66984........................... Cataract surg w/iol, 1 stage.......... 1,017 0 1
43239........................... Upper GI endoscopy, biopsy............ 156 -5 -17
45378........................... Diagnostic colonoscopy................ 141 -4 -14
45380........................... Colonoscopy and biopsy................ 115 -4 -14
45385........................... Lesion removal colonoscopy............ 95 -4 -14
66821........................... After cataract laser surgery.......... 89 -8 -25
62311........................... Inject spine l/s (cd)................. 75 -3 -10
64483........................... Inj foramen epidural l/s.............. 43 -3 -10
66982........................... Cataract surgery, complex............. 39 0 1
45384........................... Lesion remove colonoscopy............. 39 -4 -14
G0121........................... Colon ca scrn not hi rsk ind.......... 36 -7 -22
G0105........................... Colorectal scrn; hi risk ind.......... 28 -7 -22
15823........................... Revision of upper eyelid.............. 26 4 12
43235........................... Uppr gi endoscopy, diagnosis.......... 24 1 4
52000........................... Cystoscopy............................ 23 -6 -21
64475........................... Inj paravertebral l/s................. 23 -3 -10
[[Page 66919]]
64476........................... Inj paravertebral l/s ADD-on.......... 22 -18 -65
29881........................... Knee arthroscopy/surgery.............. 17 22 55
64721........................... Carpal tunnel surgery................. 16 17 43
43248........................... Uppr gi endoscopy/guide wire.......... 14 -5 -17
62310........................... Inject spine c/t...................... 13 -3 -10
67904........................... Repair eyelid defect.................. 12 6 16
29880........................... Knee arthroscopy/surgery.............. 12 22 55
64484........................... Inj foramen epidural ADD-on........... 12 -12 -42
28285........................... Repair of hammertoe................... 10 17 44
G0260........................... Inj for sacroiliac jt anesth.......... 10 -3 -10
29848........................... Wrist endoscopy/surgery............... 9 -3 -8
64623........................... Destr paravertebral n ADD-on.......... 9 -3 -10
45383........................... Lesion removal colonoscopy............ 8 -4 -14
26055........................... Incise finger tendon sheath........... 8 13 35
----------------------------------------------------------------------------------------------------------------
Over time, we believe that the current ASC payment system has
served as an incentive to ASCs to focus on providing procedures for
which they determine Medicare payments will support the ASC's continued
operation. We note that, under the existing payment system, the ASC
payment rates for many of the most frequently performed procedures in
ASCs are similar to the OPPS payment rates for the same procedures.
Conversely, we note that procedures with existing ASC payment rates
that are substantially lower than the OPPS rates are performed least
often in ASCs. We believe the revised ASC payment system represents a
major stride towards encouraging greater efficiency in ASCs and
promoting a significant increase in the breadth of surgical procedures
performed in ASCs, because it distributes payments across the entire
spectrum of covered surgical procedures, based on a coherent system of
relative payment weights that are related to the clinical and facility
resource characteristics of those procedures.
Table 64 identifies a number of ASC procedures receiving the most
Medicare estimated CY 2008 payment under the current system and shows
that most of them will experience payment decreases in CY 2008 under
the revised ASC payment system. This contrasts with the estimated
aggregate payment increases at the surgical specialty group level
displayed in Table 63. In fact, Table 63 shows only one surgical
specialty group of procedures for which the payments are expected to
decrease in the first year under the revised ASC payment system, and
only two groups for which a decrease would be expected if there were no
transition period to the revised CY 2008 payment rates. The estimated
increased payments at the full group level are due to the moderating
effect of the payment increases for the less frequently performed
procedures within the surgical specialty group. The exception to this
is the surgical specialty group of eye and ocular adnexa where the
projected aggregate increase in CY 2008 under the revised system is
driven by a very small increase, less than 1 percent, in payment for
the highest volume procedure (CPT code 66984, Extracapsular cataract
removal with insertion of intraocular lens prosthesis (one stage
procedures), manual or mechanical technique (e.g., irrigation and
aspiration or phacoemulsification)).
As a result of the redistribution of payments across the expanded
breadth of surgical procedures for which Medicare will provide an ASC
payment, we believe that ASCs may change the mix of services they
provide over the next several years. The revised ASC payment system
should encourage ASCs to expand their service-mix beyond the handful of
the highest paying procedures which comprise the majority of ASC
utilization under the existing ASC payment system. For example,
although the payment rate for cystoscopy (CPT code 52000), the highest
volume ASC genitourinary procedure, is 6 percent less for CY 2008 than
under the existing payment system, overall payment to ASCs for the
group of genitourinary procedures currently performed in ASCs is
expected to increase by 11 percent. Although a urology specialty ASC
may currently perform more cystoscopy procedures than any other
genitourinary procedure, we believe that under the revised ASC payment
system, each ASC has the opportunity to adapt to the payment decrease
for its most frequently performed procedures by offering an increased
breadth of procedures, still within the clinical specialty area, and
receive payments that are adequate to support continued operations.
Similarly, payment for all of the highest volume pain management
injection procedures are expected to decrease in CY 2008, although
payment for nervous system procedures overall are expected to increase.
However, if there were no transition period, we estimate that CY 2008
payments also would decrease slightly for the nervous system surgical
specialty group.
We note that the estimated percent changes in payment under the
revised ASC payment system for the surgical procedures with the highest
aggregate Medicare ASC payments closely resemble those presented in the
CY 2008 OPPS/ASC proposed rule, with the exception of CPT codes 64476
(Injection, anesthetic agent and/or steroid, paravertebral facet joint
or facet joint nerve; lumbar or sacral, each additional level (List
separately in addition to code for primary procedure)); and 64484
(Injection, anesthetic agent and/or steroid, transforaminal epidural;
lumbar or sacral, each additional level (List separately in addition to
code for primary procedure)). Our estimates of the percent changes in
ASC payment for these two injection procedures are
[[Page 66920]]
considerably greater for this final rule than they were for the CY 2008
OPPS/ASC proposed rule. Both of these nervous system procedures had
significantly more single claims available for OPPS ratesetting for
this final rule with comment period, reflecting much lower costs that
their median costs for the proposed rule. These data resulted in the
reassignment of CPT codes 64476 and 64484 to different clinical APCs
for CY 2008 than proposed, in order to ensure the clinical and resource
homogeneity of the OPPS APCs for CY 2008. Their lower OPPS payment
rates in turn resulted in lower payments than those estimated in the
proposed rule for the two services under the revised ASC payment
system. However, as shown in Table 63, above, the final estimated
decrease in ASC payment for nervous system procedures overall without
the transition is estimated to be 4 percent in this final rule with
comment period, very close to the CY 2008 OPPS/ASC proposed rule
estimated decrease of 2 percent for nervous system procedures. Thus, we
believe that our final policies will continue to ensure Medicare
beneficiary access to surgical procedures involving the nervous system
in ASCs under the revised ASC payment system in CY 2008.
For those procedures that will be paid a significantly lower amount
under the revised payment system than they are currently paid, we
believe that their current payment rates, which are closer to the OPPS
payment rates than are the rates for other ASC procedures, are likely
to be generous relative to ASC costs, so ASCs would, in all likelihood,
continue performing those procedures under the revised payment system.
We also note that the majority of the most frequently performed ASC
procedures specifically studied by the GAO for its report to Congress
on ASC costs, as described in the August 2, 2007 revised ASC payment
system final rule (72 FR 42474), appear in Table 64 with payment
decreases under the revised ASC payment system. The GAO concluded that
for those procedures the OPPS APC groups accurately reflect the
relative costs of procedures performed at ASCs and that ASCs have
substantially lower costs.
For some procedures, the payment amounts in CY 2008 are much higher
than the CY 2007 rates currently paid to ASCs. For example, payments
for CPT codes 29880 (Arthroscopy, knee, surgical; with meniscectomy
(medial AND lateral, including any meniscal shaving)) and 29881
(Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral,
including meniscal shaving)) increase by 22 percent. For these two
procedures and the other procedures with estimated payment increases
greater than 10 percent, the increases are due to the comparatively
higher OPPS rates which, when adjusted by the ASC budget neutrality
factor and blended with the CY 2007 ASC payment amounts, generate CY
2008 ASC payment rates that are substantially above the current CY 2007
ASC payment amounts.
As indicated elsewhere in this final rule with comment period,
payments for most of the highest volume colonoscopy and upper
gastrointestinal endoscopy procedures will decrease under the revised
payment system. Table 63 estimates that payment decreases also are
expected for the digestive system surgical specialty group overall. We
believe that the reason for decreased payments for so many of the
digestive system procedures is that the current ASC payment rates are
close to the OPPS rates. Procedures with current payment rates that are
nearly as high as their OPPS rates are negatively affected under the
revised payment system while procedures for which ASC rates have
historically been much lower than the comparable OPPS rates are
positively affected. The payment decreases expected in the first year
under the revised ASC payment system for some of the high volume
digestive system procedures are not large (all less than or equal to 7
percent). We believe that ASCs can generally continue to cover their
costs for these procedures, and that ASCs specializing in providing
those services will be able to adapt their business practices and case
mix to manage declines for individual procedures.
In addition to the procedures currently on the ASC list of covered
surgical procedures discussed above, in CY 2008 we also are adding
hundreds of surgical procedures to the already extensive list of
procedures for which Medicare allows payment to ASCs, creating new
opportunities for ASCs to expand their range of covered surgical
procedures. For the first time, ASCs will be paid separately for
covered ancillary services that are integral to covered surgical
procedures, including certain radiology procedures, costly drugs and
biologicals, devices with pass-through status under the OPPS, and
brachytherapy sources. While separately paid radiology services will be
paid based on their ASC relative payment weight calculated according to
the standard ratesetting methodology of the revised ASC payment system
or the MPFS nonfacility PE RVU amount, whichever is lower, the other
covered ancillary items and services newly eligible for separate
payment in ASCs will be paid comparably to their OPPS rates because we
would not expect ASCs to experience efficiencies in providing them.
Lastly, the August 2, 2007 revised ASC payment system final rule
established a specific payment methodology for device-intensive
procedures that provides the same packaged payment for the device as
under the OPPS, while providing a reduced service payment that is
subject to the 4-year transition if the device-intensive procedure is
on the CY 2007 ASC list of covered surgical procedures. We expect that
this final methodology will allow ASCs to continue to expand their
provision of device-intensive services and to begin performing new
device-intensive ASC procedures.
b. Payment to Physicians for Performing Excluded ASC Procedures in an
ASC
As discussed in section XVI.G. of this final rule with comment
period, we are paying physicians at the facility rate for furnishing
procedures in ASCs that are excluded from the ASC list of covered
procedures. This policy reduces site of service (facility versus
nonfacility) differentials that currently exist and aligns physician
payment policies for services furnished in ASCs and HOPDs.
We believe that the effect of the change will be small. Currently,
physicians are paid for procedures performed in ASCs that are not on
the list of ASC covered surgical procedures based on the nonfacility PE
RVUs, unless a nonfacility rate does not exist, in which case they are
paid based on the facility rate. For CY 2008, we excluded procedures
from the ASC list of covered surgical procedures because they could
pose a significant risk to beneficiary safety or would be expected to
require an overnight stay and, as such, the excluded procedures are
generally more complex than procedures furnished in physicians'
offices. Consequently, most surgical procedures that are excluded from
the list of ASC covered surgical procedures in CY 2008 do not have
nonfacility PE RVUs. Specifically, only about 46 of approximately 2,000
excluded ASC procedures for CY 2008 have nonfacility PE RVUs. As a
result, even under our current policy, physicians performing an
excluded ASC procedure in an ASC would be paid for most excluded
procedures based on the facility PE RVUs. Thus, our policy to pay
physicians for excluded ASC procedures performed in ASCs based on the
facility PE RVUs will only affect Medicare payment rates for the small
proportion of excluded procedures that have nonfacility PE RVUs.
[[Page 66921]]
4. Estimated Effects of This Final Rule With Comment Period on
Beneficiaries
a. Payment to ASCs
We estimate that the changes for CY 2008 will be positive for
beneficiaries in at least two respects. Except for screening
colonoscopy and flexible sigmoidoscopy procedures, the ASC coinsurance
rate for all procedures is 20 percent. This contrasts with procedures
performed in HOPDs where the beneficiary is responsible for copayments
that range from 20 percent to 40 percent. In addition, ASC payment
rates under the revised payment system are lower than payment rates for
the same procedures under the OPPS, so the beneficiary coinsurance
amount under the ASC payment system almost always will be less than the
OPPS copayment amount for the same services. (The only exceptions will
be when the ASC coinsurance amount exceeds the inpatient deductible.
The statute requires that copayment amounts under the OPPS not exceed
the inpatient deductible.) Beneficiary coinsurance for services
migrating from physicians' offices to ASCs may decrease or increase
under the revised ASC payment system, depending on the particular
service and the relative payment amounts for that service in the
physician's office compared with the ASC. As noted previously, the net
effect of the revised ASC payment system on beneficiary coinsurance,
taking into account the migration of services from HOPDs and
physicians' offices, is estimated to be $20 million in beneficiary
savings in CY 2008.
In addition to the lower out-of-pocket expenses, we believe that
beneficiaries also will have access to more services in ASCs as a
result of the addition of approximately 800 surgical procedures to the
ASC list of covered surgical services eligible for Medicare payment in
CY 2008. We expect that ASCs will provide a broader range of surgical
services under the revised payment system and that beneficiaries will
benefit from having access to a greater variety of surgical procedures
in ASCs.
b. Payment to ASCs for Excluded Procedures Performed in an ASC
In addition, the revision to Sec. Sec. 414.22(b)(5)(i)(A) and (B)
will impose beneficiary liability for facility costs associated with
surgical procedures that are not Medicare covered surgical procedures
in ASCs. In the August 2, 2007 revised ASC payment system final rule,
CMS determined that the only surgical procedures that will be excluded
from ASC payment in CY 2008 are those that could pose a significant
safety risk to beneficiaries when furnished in an ASC or are expected
to require an overnight stay when furnished in ASCs and, therefore,
Medicare provides no payment to ASCs for these procedures. The revision
to Sec. Sec. 414.22(b)(5)(i)(A) and (B) will also provide for no
payment to physicians for the facility resources required to furnish
excluded services in ASCs, leaving the beneficiary liable for the
facility payment if a surgical procedure excluded by Medicare from ASC
payment is, in fact, performed in the ASC setting. We do not expect
that the change will result in a meaningful increase in beneficiary
liability because we do not expect that excluded services, which we
have determined could pose a significant risk to beneficiary safety or
would be expected to require an overnight stay, will be furnished to
Medicare beneficiaries in ASCs. Furthermore, we expect that physicians
and ASCs will advise beneficiaries of all of the possible consequences
(including denial of Medicare payment with concomitant beneficiary
liability and significant surgical risk) if surgical procedures
excluded from ASC payment are provided in ASCs.
5. Conclusion
The changes to the ASC payment system for CY 2008 will affect each
of the approximately 4,800 ASCs currently approved for participation in
the Medicare program. The effect on an individual ASC will depend on
the ASC's mix of patients, the proportion of the ASC's patients that
are Medicare beneficiaries, the degree to which the payments for the
procedures offered by the ASC are changed under the revised payment
system, and the degree to which the ASC chooses to provide a different
set of procedures.
The revised ASC payment system is designed to result in the same
aggregate amount of Medicare expenditures in CY 2008 that would be made
in the absence of the revised ASC payment system. As mentioned
previously, we estimate that the revised ASC payment system and the
expanded ASC list of covered surgical procedures that we are
implementing in CY 2008 will have no net effect on Medicare
expenditures compared to the level of Medicare expenditures that would
have occurred in CY 2008 in the absence of the revised payment system.
However, there will be a total increase in Medicare payments to ASCs
for CY 2008 of approximately $240 million as a result of the revised
ASC payment system, which will be fully offset by savings from reduced
Medicare spending in HOPDs and physicians' offices on services that
migrate from these settings to ASCs (as discussed in detail in section
XVI.L. of this final rule with comment period). Furthermore, we
estimate that the revised ASC payment system will result in Medicare
savings of $220 million over 5 years due to migration of new ASC
services from HOPDs and physicians' offices to ASCs over time. We
anticipate that this final rule with comment period will have a
significant economic impact on a substantial number of small entities.
6. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehousegov/omb/circulars/a004/a-4.pdf), in Table 65 below, we
have prepared an accounting statement showing the classification of the
expenditures associated with the implementation of the CY 2008 revised
ASC payment system, based on the provisions of this final rule with
comment period. As explained above, we estimate that Medicare payments
to ASCs for CY 2008 will be about $240 million higher than they
otherwise would be in the absence of the revised ASC payment system.
This $240 million in additional payments to ASCs will be fully offset
by savings from reduced Medicare spending in HOPDs and physicians'
offices on services that migrate from these settings to ASCs. This
table provides our best estimate of Medicare payments to providers and
suppliers as a result of the CY 2008 revised ASC payment system, as
presented in this final rule with comment period. All expenditures are
classified as transfers.
Table 65.--Accounting Statement: Classification of Estimated
Expenditures From CY 2007 to CY 2008 as a Result of the CY 2008 Revised
ASC Payment System
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............ $0 Million.
From Whom to Whom......................... Federal Government to
Medicare Providers and
Suppliers.
Annualized Monetized Transfer............. $0 Million.
From Whom to Whom......................... Premium Payments from
Beneficiaries to Federal
Government.
-----------------------------
Total................................. $0 Million.
------------------------------------------------------------------------
[[Page 66922]]
D. Effects of the Requirements for Reporting of Quality Data for
Hospital Outpatient Settings
In section XVII. of this final rule with comment period, we discuss
our measures and requirements for reporting of quality data to CMS for
services furnished in hospital outpatient settings under the HOP QDRP.
We note that we have reduced the number of initial quality measures to
be reported from the 10 we proposed to 7. We have also modified the
date for which the initial submission of quality data begins from
services furnished on or after January 2008 to services furnished on or
after April 2008. The initial submission for data for April-June 2008
services is due to the OPPS Clinical Warehouse by November 1, 2008. CMS
and its contractors will provide assistance to all hospitals that wish
to submit data. In addition, we have modified our proposal for the CY
2009 payment update, so that hospitals are not required to submit
charts for or pass our validation requirement of a minimum of 80
percent reliability, based upon our chart-audit validation process for
January 2008 services. As noted in section XVII.E. of this final rule
with comment period, we are providing validation criteria for services
furnished on or after July 1, 2008 for purposes of the CY 2010 and
subsequent years' payment updates to ensure that the quality data being
sent to CMS are accurate. The requirement of five charts per hospital
per quarter will result in the submission of approximately 21,500
charts per quarter for services furnished on or after July 1, 2008 to
the agency. We believe that a requirement for five charts per hospital
per quarter for services furnished on or after July 1, 2008, represents
a minimal burden to the participating hospital.
E. Effects of Policy Revisions on CAH Off-Campus and Co-Location
Requirements
In section XVIII.A. of the preamble of this final rule with comment
period, we discuss our changes regarding a CAH's ability to co-locate
with another acute care hospital or establish an off-campus location
that does not comply with the location requirements (more than a 35-
mile drive, or in the case of mountainous terrain or in areas with only
secondary roads available, a 15-mile drive) for CAHs. We clarified in
this final rule with comment period that if a CAH with a necessary
provider designation has a co-location arrangement with another
hospital or CAH that was in effect before January 1, 2008, and the type
and scope of services offered by the facilities co-located with the
necessary provider CAH do not change, the CAH can continue those
arrangements. In addition, if a CAH (including one with a necessary
provider designation) acquires or creates an off-campus provider-based
location or an off-campus distinct part psychiatric or rehabilitation
unit on or after January 1, 2008, the CAH off-campus provider-based
facility must comply with the location requirements. We revised the
language of the regulation to exclude RHCs, as defined under Sec.
405.2401(b), from the list of provider-based facilities that must
comply with this regulation. Because CAHs can continue current co-
location and off-campus arrangements that are in place before January
1, 2008, we believe there is no burden associated with this regulation.
F. Effects of Policy Revisions to the Hospital CoPs
In section XVIII.B. of the preamble of this final rule with
comment, we discuss changes to the hospital CoPs relating to timeframes
for completion of medical history and physical examinations and
requirements for preanesthesia and postanesthesia evaluations of
Medicare beneficiaries. We believe that these revisions would impose
minimal additional costs on hospitals. In fact, hospitals may realize
some minimal cost savings. The cost of implementing these changes would
largely be limited to the one-time cost related to the revision of a
hospital's medical staff bylaws and its policies and procedures as they
relate to the requirements for medical history and physical
examinations and for preanesthesia and postanesthesia evaluations.
There also may be some minimal cost associated with communicating these
changes to affected hospital staff. However, we believe that these
costs would be offset by the benefits derived from the overall intent
of these revisions to require that the most current information
regarding a patient's condition be available to hospital staff so that
risks to patient safety can be minimized and potential adverse outcomes
can be avoided. Furthermore, the changes would clarify existing
hospital CoPs to make them more consistent with current practice, while
still retaining the flexibility and reduction in burden that hospitals
are currently provided in meeting those CoPs. Therefore, no burden is
being assessed on the revision of medical staff bylaws and hospital
policies and procedures or on the communication of these revisions to
staff that would be required by these revisions as these practices are
usual and customary business practices.
In accordance with the provisions of Executive Order 12866, this
final rule with comment period was reviewed by the OMB.
G. Impact of the Changes to the Hospital Inpatient Prospective Payment
System (IPPS) Payment Rates
1. Overall Impact
We have examined the impacts of this final rule relating to the
changes to hospital inpatient prospective payment system payment rates
as required by Executive Order 12866 (September 1993, Regulatory
Planning and Review), section 1102(b) of the Social Security Act, the
Unfunded Mandates Reform Act of 1995 (Public Law 104-4), and Executive
Order 13132. We have also examined the impacts of this final rule in
the context of the Regulatory Flexibility Act (RFA) (September 19,
1980, Public Law 96-354).
Based on the IPPS provisions specified in section XIX. of this
final rule, we have determined that this rule is a major rule as
defined in 5 U.S.C. 804(2). This final rule includes changes in FY 2008
IPPS payments due to the enactment of Public Law 110-90, which requires
the Secretary to apply a prospective documentation and coding
adjustment for discharges during FY 2008 of -0.6 percent rather than
the -1.2 percent specified in the FY 2008 IPPS final rule. In addition,
this final rule includes a change in policy to not apply the
documentation and coding adjustment to the hospital-specific payment
rates. We estimate that the increase in FY 2008 IPPS operating and
capital payments to hospitals resulting from the provisions of this
final rule will be in excess of $100 million.
With the exception of the IPPS changes included in this final rule,
all FY 2008 IPPS payment policies were established in the FY 2008 IPPS
final rule (72 FR 47130) issued on August 1, 2007. As noted in section
XIX. of this document, on September 28, 2007, we issued a notice
relating to the FY 2008 IPPS final rule that corrected a technical
calculation and typographical errors in that final rule. The correction
notice appeared in the October 10, 2007 Federal Register and is
hereinafter referred to as the ``second FY 2008 IPPS correction
notice.'' In the second FY 2008 IPPS correction notice, we estimated a
$4.0 billion increase in FY 2008 operating and capital payments as a
result of the market basket update to the FY 2008 IPPS rates required
by the statute, in conjunction with the other payment policies
established in the FY
[[Page 66923]]
2008 IPPS final rule. In this final rule, we have updated our estimate
of the increase in FY 2008 IPPS operating and capital payments based on
the policies and market basket update established in the FY 2008 IPPS
final rule and the addition of the IPPS provisions included in this
final rule. We now estimate an increase in FY 2008 operating and
capital payments of approximately $4.6 billion, an increase of about
$665 million over our prior estimate. Our current estimate includes the
statutorily mandated -0.6 percent adjustment for documentation and
coding changes to the IPPS standardized amounts and capital Federal
rates for FY 2008 under section 7 of Public Law 110-90, and the removal
of the application of the documentation and coding adjustment to the
hospital-specific rates. For purposes of the impact analysis, we also
assume a 1.2 percent increase in case-mix growth, as determined by the
Office of the Actuary, because we believe the adoption of the MS-DRGs
will result in case-mix growth due to documentation and coding changes
that do not reflect real changes in patient severity of illness. The
estimates do not reflect any other changes in hospital admissions or
case-mix intensity in operating PPS payments, which will also affect
overall payment changes.
The RFA requires agencies to analyze options for regulatory relief
of small businesses for any rule for which the agency publishes a
general notice of proposed rulemaking. Since we have waived notice and
comment rulemaking for the IPPS provisions in this final rule as
discussed in section XIX.C. of this final rule, we do not believe the
Regulatory Flexibility Act requires a regulatory flexibility analysis
in this case. While we do not believe we are required to perform a
regulatory flexibility analysis, we are including in section XIX. of
this final rule and in this impact analysis section final rule all of
the components that would be required of a final regulatory flexibility
analysis.
For purposes of the RFA, small entities include small businesses,
nonprofit organizations, and government agencies. Most hospitals and
most other providers and suppliers are considered to be small entities,
either by nonprofit status or by having revenues of $31.5 million or
less in any 1 year. (For details on the latest standards for heath care
providers, we refer readers to page 33 of the Table of Small Business
Size Standards at the Small Business Administration Web site at: http://www.sba.gov/services/contractingopportunities/sizestandardstopics/tableofsize/index.html.) For purposes of the RFA, all hospitals and
other providers and suppliers are considered to be small entities.
Individuals and States are not included in the definition of a small
entity. We believe that the IPPS payment rate changes in this final
rule will have a significant impact on small entities as explained
subsequently.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis for any proposed or final rule that may have
a significant impact on the operations of a substantial number of small
rural hospitals. This analysis must conform to the provisions of
section 604 of the RFA. With the exception of hospitals located in
certain New England counties, for purposes of section 1102(b) of the
Act, we now define a small rural hospital as a hospital that is located
outside of an urban area and has fewer than 100 beds. Section 601(g) of
the Social Security Amendments of 1983 (Public Law 98-21) designated
hospitals in certain New England counties as belonging to the adjacent
urban area. Thus, for purposes of the IPPS, we continue to classify
these hospitals as urban hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 (Public Law
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. This IPPS
changes in this final rule will not mandate any requirements for State,
local, or tribal governments, nor will it affect private sector costs.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. As stated above, the IPPS changes in this final rule will
not have a substantial effect on State and local governments.
The following analysis, in conjunction with the section XIX. of
this document, demonstrates that this rule is consistent with the
regulatory philosophy and principles identified in Executive Order
12866, the RFA, and section 1102(b) of the Act. The rule will affect
payments to a substantial number of small rural hospitals, as well as
other classes of hospitals, and the effects on some hospitals may be
significant.
2. Objectives
The primary objective of the IPPS is to create incentives for
hospitals to operate efficiently and minimize unnecessary costs while
at the same time ensuring that payments are sufficient to adequately
compensate hospitals for their legitimate costs. In addition, we share
national goals of preserving the Medicare Hospital Insurance Trust
Fund.
We believe that the policies established in the FY 2008 IPPS final
rule and the IPPS provisions of this final rule will further each of
these goals while maintaining the financial viability of the hospital
industry and ensuring access to high quality health care for Medicare
beneficiaries. We expect that these changes will ensure that the
outcomes of this payment system are reasonable and equitable while
avoiding or minimizing unintended adverse consequences.
3. Limitations of Our Analysis
The following quantitative analysis presents the projected effects
of our IPPS policy changes, as well as statutory changes effective for
FY 2008, on various hospital groups. We use the best available data,
but generally do not attempt to make adjustments for future changes in
such variables as admissions, length of stay, or case-mix. However, as
stated in the FY 2008 IPPS final rule, we believe that adoption of the
MS-DRGs will create a risk of increased aggregate levels of payment as
a result of more comprehensive documentation and coding. As explained
in section XIX. of this final rule, the FY 2008 IPPS final rule
established a documentation and coding adjustment of -1.2 percent to
maintain budget neutrality for the transition to the MS-DRGs.
Subsequently, Congress enacted Public Law 110-90, which reduced the FY
2008 IPPS documentation and coding adjustment from -1.2 percent to -0.6
percent. Therefore, in section XIX. of this final rule, we have revised
the payment rates, factors and thresholds to reflect the -0.6 percent
documentation and coding adjustment. While the documentation and coding
adjustment has been changed for payment purposes, we continue to
believe that an increase in case mix of 1.2 percent in FY 2008 is
likely as a result of the adoption of the MS-DRGs. The impacts shown
below illustrate the impact of the FY 2008 IPPS changes on hospital
operating payments, including the -0.6 percent documentation and coding
adjustment to the IPPS standardized amounts, both prior to and
following the projected 1.2 percent growth in case-mix.
[[Page 66924]]
4. Quantitative Effects of the IPPS Policy Changes for Operating Costs
In this final rule, we are employing the same operating payment
simulation model as used in the FY 2008 IPPS final rule. Our
methodology underlying the simulation model is discussed in detail in
the FY 2008 IPPS final rule (72 FR 48158 through 48159). The difference
between the impact estimates in this final rule and the FY 2008 IPPS
final rule reflects the application of a documentation and coding
adjustment of -0.6 percent (instead of -1.2 percent) and the removal of
the application of the documentation and coding adjustment to the
hospital-specific rates. Our impact estimates in this final rule also
reflect a technical correction to a calculation error made in our
previously published impact estimates, as discussed in more detail
subsequently.
5. Analysis of Table I
Table I displays the estimated increase in IPPS operating payments
between FY 2007 and FY 2008. It compares the impact estimates
previously published in the second FY 2008 IPPS correction notice to
the FY 2008 IPPS final rule, which is based on the payment policies and
market basket update established in the FY 2008 IPPS final rule, with
our current impact estimates, which are based on both the IPPS policies
established in the FY 2008 IPPS final rule and the IPPS policy changes
included in this final rule.
As noted previously, we believe that the adoption of the MS-DRGs in
FY 2008 will create a financial risk of increased aggregate payments as
a result of more comprehensive documentation and coding. To maintain
budget neutrality, the FY 2008 IPPS final rule established a
documentation and coding adjustment of -1.2 percent for FY 2008.
Subsequently, Public Law 110-90 was enacted, which reduces the FY 2008
documentation and coding adjustment from -1.2 percent to -0.6 percent.
Thus, our previously published impact estimates reflect a -1.2 percent
documentation and coding adjustment and our current impact estimates
reflect a -0.6 percent adjustment. While the documentation and coding
adjustment has been changed for payment purposes, we continue to
believe that an increase in case-mix of 1.2 percent for FY 2008 is
likely to occur. Table 1 illustrates the impact of the FY 2008 IPPS
changes on hospital payments, including the documentation and coding
adjustment to the IPPS standardized amounts, both prior to and
following the projected 1.2 percent growth in case-mix.
The table categorizes hospitals by various geographic and special
payment considerations to illustrate the varying impacts on different
types of hospitals. The top row of the table shows the overall impact
on the 3,534 hospitals included in the analysis.
The next four rows of Table I contain hospitals categorized
according to their geographic location: All urban, which is further
divided into large urban and other urban; and rural. There are 2,539
hospitals located in urban areas included in our analysis. Among these,
there are 1,406 hospitals located in large urban areas (populations
over 1 million), and 1,133 hospitals in other urban areas (populations
of 1 million or fewer). In addition, there are 995 hospitals in rural
areas. The next two groupings are by bed size categories, shown
separately for urban and rural hospitals. The final groupings by
geographic location are by census divisions, also shown separately for
urban and rural hospitals.
The second part of Table I shows hospital groups based on
hospitals' FY 2008 payment classifications, including any
reclassifications under section 1886(d)(10) of the Act. For example,
the rows labeled urban, large urban, other urban, and rural show that
the number of hospitals paid based on these categorizations after
consideration of geographic reclassifications (including
reclassifications under section 1886(d)(8)(B) and section 1886(d)(8)(E)
of the Act that have implications for capital payments) are 2,578,
1,425, 1,153, and 956, respectively.
The next three groupings examine the impacts of the changes on
hospitals grouped by whether or not they have GME residency programs
(teaching hospitals that receive an IME adjustment) or receive DSH
payments, or some combination of these two adjustments. There are 2,480
nonteaching hospitals in our analysis, 815 teaching hospitals with
fewer than 100 residents, and 239 teaching hospitals with 100 or more
residents.
In the DSH categories, hospitals are grouped according to their DSH
payment status, and whether they are considered urban or rural for DSH
purposes. The next category groups together hospitals considered urban
after geographic reclassification, in terms of whether they receive the
IME adjustment, the DSH adjustment, both, or neither.
The next five rows examine the impacts of the changes on rural
hospitals by special payment groups (SCHs, RRCs, and MDHs), as well as
rural hospitals not receiving a special payment designation. There were
194 RRCs, 367 SCHs, 150 MDHs, 99 hospitals that are both SCHs and RRCs,
and 8 hospitals that are both an MDH and an RRC.
The next series of groupings concern the geographic
reclassification status of hospitals. The first grouping displays all
urban hospitals that were reclassified by the MGCRB for FY 2008. The
second grouping shows the MGCRB rural reclassifications.
The final two groupings are based on the type of ownership and the
hospital's Medicare utilization expressed as a percent of total patient
days. These data were taken from the FY 2004 Medicare cost reports.
Table I.--Impact Analysis of Changes for FY 2008
----------------------------------------------------------------------------------------------------------------
Previously Current Previously Current
published estimate of published estimate of
all FY 2008 all FY 2008 all FY 2008 all FY 2008
changes w/ changes w/ changes w/ changes w/
No. of CMI CMI CMI CMI
hospitals adjustment adjustment adjustment adjustment
prior to prior to and and
estimated estimated estimated estimated
growth \11\ growth \12\ growth \13\ growth \14\
(1) (2a) (2b) (3a) (3b)
----------------------------------------------------------------------------------------------------------------
All Hospitals.................................. 3,534 2.5 3.1 3.7 4.3
By Geographic Location:
Urban hospitals............................ 2,539 2.6 3.3 3.9 4.5
Large urban areas.......................... 1,406 3.1 3.7 4.3 5.0
Other urban areas.......................... 1,133 2 2.7 3.3 3.9
[[Page 66925]]
Rural hospitals............................ 995 1.2 1.7 2.4 2.9
Bed Size (Urban):
0-99 beds.................................. 630 1 1.6 2.2 2.8
100-199 beds............................... 851 2.3 2.9 3.6 4.2
200-299 beds............................... 480 2.5 3.1 3.8 4.4
300-499 beds............................... 411 3 3.6 4.2 4.8
500 or more beds........................... 167 2.9 3.5 4.1 4.8
Bed Size (Rural):
0-49 beds.................................. 337 0.1 0.5 1.3 1.7
50-99 beds................................. 372 1.2 1.6 2.4 2.9
100-149 beds............................... 173 1.2 1.8 2.5 3.0
150-199 beds............................... 68 1.2 1.8 2.5 3.0
200 or more beds........................... 45 1.8 2.3 3.1 3.6
Urban by Region:
New England................................ 122 2.4 3.0 3.7 4.3
Middle Atlantic............................ 350 2.2 2.9 3.5 4.1
South Atlantic............................. 390 2.7 3.4 4 4.6
East North Central......................... 395 2.4 3.0 3.7 4.3
East South Central......................... 166 2.1 2.7 3.3 3.9
West North Central......................... 157 2.4 3.0 3.6 4.2
West South Central......................... 355 2.6 3.2 3.8 4.4
Mountain................................... 153 2.6 3.2 3.8 4.4
Pacific.................................... 398 4 4.6 5.2 5.8
Puerto Rico................................ 53 2.9 3.5 4.1 4.8
Rural by Region:
New England................................ 23 1.2 1.6 2.4 2.8
Middle Atlantic............................ 72 1.4 1.8 2.6 3.0
South Atlantic............................. 173 1.6 2.2 2.8 3.4
East North Central......................... 122 1.4 1.8 2.7 3.1
East South Central......................... 177 0.9 1.5 2.1 2.7
West North Central......................... 115 1.4 1.8 2.6 3.0
West South Central......................... 199 -0.3 0.3 0.9 1.5
Mountain................................... 77 2 2.4 3.2 3.6
Pacific.................................... 37 2.9 3.3 4.2 4.6
By Payment Classification:
Urban hospitals............................ 2,578 2.6 3.3 3.9 4.5
Large urban areas.......................... 1,425 3.1 3.7 4.3 4.9
Other urban areas.......................... 1,153 2 2.6 3.3 3.9
Rural areas................................ 956 1.3 1.7 2.5 3.0
Teaching Status:
Nonteaching................................ 2,480 2.1 2.7 3.3 3.9
Fewer than 100 residents................... 815 2.5 3.1 3.8 4.4
100 or more residents...................... 239 3.1 3.8 4.4 5.0
Urban DSH:
Non-DSH.................................... 859 1.7 2.3 3 3.6
100 or more beds........................... 1,512 2.9 3.5 4.1 4.7
Less than 100 beds......................... 355 1.9 2.5 3.1 3.7
Rural DSH:
SCH........................................ 384 1.6 2.0 2.9 3.2
RRC........................................ 203 1.3 1.9 2.5 3.1
100 or more beds........................... 46 1.4 2.0 2.6 3.3
Less than 100 beds......................... 175 0.2 0.8 1.4 2.1
Urban teaching and DSH:
Both teaching and DSH...................... 807 3 3.6 4.2 4.8
Teaching and no DSH........................ 186 1.9 2.5 3.2 3.8
No teaching and DSH........................ 1,060 2.6 3.2 3.8 4.4
No teaching and no DSH..................... 525 1.7 2.3 2.9 3.6
Special Hospital Types:
RRC........................................ 194 1.5 2.1 2.7 3.3
SCH........................................ 367 1.3 1.6 2.5 2.8
MDH........................................ 150 2 2.3 3.2 3.6
SCH and RRC................................ 99 1.7 2.0 2.9 3.3
MDH and RRC................................ 8 1.3 1.5 2.6 2.7
Type of Ownership:
[[Page 66926]]
Voluntary.................................. 2,064 2.4 3.0 3.6 4.2
Proprietary................................ 823 2.7 3.3 4 4.6
Government................................. 597 2.7 3.3 3.9 4.5
Medicare Utilization as a Percent of Inpatient
Days:
0-25....................................... 230 4.2 4.9 5.5 6.1
25-50...................................... 1,289 3.1 3.7 4.3 4.9
50-65...................................... 1,451 1.9 2.4 3.1 3.7
Over 65.................................... 440 1.2 1.8 2.5 3.0
FY 2008 Reclassifications by the Medicare
Geographic Classification Review Board:
All Reclassified Hospitals................. 738 2.2 2.8 3.4 4.0
Non-Reclassified Hospitals................. 2,796 2.6 3.2 3.8 4.4
Urban Hospitals Reclassified............... 372 2.4 3.1 3.7 4.3
Urban Nonreclassified, FY 2008:............ 2,147 2.7 3.3 3.9 4.5
All Rural Hospitals Reclassified Full Year 366 1.6 2.1 2.8 3.3
FY 2008:..................................
Rural Nonreclassified Hospitals Full Year 566 0.4 0.9 1.7 2.1
FY 2008:..................................
All Section 401 Reclassified Hospitals:.... 26 0.6 0.8 1.8 2.0
Other Reclassified Hospitals (Section 63 1.5 2.0 2.8 3.3
1886(d)(8)(B))............................
Former 508 Hospitals....................... 107 -0.6 0.0 0.6 1.2
Specialty Hospitals:
Cardiac specialty Hospitals................ 22 -0.4 0.2 0.8 1.4
----------------------------------------------------------------------------------------------------------------
\11\ This column shows our previous estimate published in the second FY 2008 IPPS correction notice of the
changes in payments from FY 2007 to FY 2008 including a 0.988 CMI adjustment for coding and documentation
improvements that are anticipated with the adoption of the MS-DRGs prior to the estimated growth occurring. It
also reflects all FY 2008 IPPS policies adopted in the FY 2008 IPPS final rule.
\12\ This column shows our current estimate of the changes in payments from FY 2007 to FY 2008 including a 0.994
CMI adjustment for coding and documentation improvements that are anticipated with the adoption of the MS-DRGs
prior to the estimated growth occurring. It also reflects all FY 2008 IPPS policies adopted in the FY 2008
IPPS final rule and this final rule.
\13\ This column shows our previous estimate published in CMS-1533-CN2 of the changes in payments from FY 2007
to FY 2008 including a .988 CMI adjustment and the estimated case-mix growth of 1.2 percent as a result of
improvements in documentation and coding. It also reflects all FY 2008 IPPS policies adopted in the FY 2008
IPPS final rule.
\14\ This column shows our current estimate of the changes in payments from FY 2007 to FY 2008 including a .994
CMI adjustment and the estimated case-mix growth of 1.2 percent (when comparing column 2b to column 3b) as a
result of improvements in documentation and coding. It also reflects all FY 2008 IPPS policies adopted in the
FY 2008 IPPS final rule and this final rule.
a. Effects of All Changes With CMI Adjustment Prior to Estimated Growth
(Columns 2a and 2b)
Columns 2a and 2b show our previously published and current
estimates of the change in IPPS payments from FY 2007 to FY 2008,
reflecting all FY 2008 IPPS policies including a documentation and
coding adjustment to the FY 2008 rates, but not taking into account the
expected 1.2 percent growth in case-mix due to the anticipated
improvement in documentation and coding as a result of the MS-DRGs.
Because columns 2a and 2b model the impact to include the documentation
and coding adjustment for anticipated case-mix increase without
accounting for the actual case-mix increase itself, these columns
illustrate a total payment change that is less than what is anticipated
to occur.
Column 2a shows our previously published estimate in the October
10, 2007 correction notice to the FY 2008 IPPS proposed rule based on
the policies established in the FY 2008 IPPS final rule, including a -
1.2 percent documentation and coding adjustment. Column 2b shows our
current estimate based on the same FY 2008 IPPS payment policies,
except it also includes the policy changes established in this final
rule (that is, the statutorily mandated -0.6 percent documentation and
coding adjustment and the change in policy of not applying the
documentation and coding adjustment to the hospital specific rates).
Column 2b also corrects for a technical error that occurred in the
second FY 2008 IPPS correction notice that inadvertently overestimated
FY 2008 payments to providers that receive the hospital specific rate.
Comparing columns 2a and 2b, the average increase in FY 2008 IPPS
payment for all hospitals is approximately 0.6 percentage points higher
than in the second FY 2008 IPPS correction notice, as would be expected
with the statutorily mandated change in the documentation and coding
adjustment from -1.2 percent to -0.6 percent. As a result of the
combination of the law change and a policy of not applying the
documentation and coding adjustment to the hospital-specific rates for
MDHs and SCHs, certain categories of hospitals (MDHs, SCHs, rural
hospitals, and certain rural geographic areas with relatively large
numbers of SCHs and MDHs) are estimated to experience an increase in
their operating payments of slightly more than 0.6 percentage points
compared with the policies articulated in the FY 2008 IPPS final rule.
However, column 2b shows an increase in operating payments for these
categories of hospitals of only about 0.2 to 0.5 percentage points
greater than our previously published impact estimates in column 2a
(rather than more than 0.6 percentage points) due to a technical error
in our previously published impact estimates that had overstated the
[[Page 66927]]
FY 2008 increase in payments to these hospitals.
b. Effects of All Changes With CMI Adjustment and Estimated Growth
(Column 3)
Columns 3a and 3b show our previously published and current
estimates of the change in IPPS payments from FY 2007 to FY 2008,
reflecting all FY 2008 IPPS policies including a documentation and
coding adjustment to the FY 2008 rates and taking into account the
expected 1.2 percent growth in case-mix in FY 2008 due to anticipated
improvements in documentation and coding as a result of the MS-DRGs.
Column 3a shows our previously published estimate in the correction
notice to the FY 2008 IPPS proposed rule of the FY 2008 increase in
operating payments based on the policies established in the FY 2008
IPPS final rule, including a -1.2 percent documentation and coding
adjustment which is assumed to be fully offset by a 1.2 percent
increase in case-mix. Column 3b shows our current estimate based on the
same FY 2008 IPPS payment policies, except it also includes the policy
changes established in this final rule (that is, the statutorily
mandated -0.6 percent documentation and coding adjustment and the
change in policy of not applying the documentation and coding
adjustment to the hospital-specific rates). In column 3b, even though
the documentation and coding adjustment reduces the standardized amount
by 0.6 percent, this column assumes a 1.2 percent increase in case-mix
due to improved documentation and coding that is estimated to occur
equally across all hospitals as determined by the Office of the
Actuary. Furthermore, it assumes that a 1.2 percent increase in case-
mix from improved documentation and coding will occur for hospitals
that receive the hospital-specific rate. Similar to column 2b, column
3b also corrects for a technical error that occurred in the second FY
2008 IPPS correction notice that inadvertently overstated the FY 2008
increase in payments to providers that receive the hospital specific-
rate.
Column 3b reflects our current estimate of the impact of all FY
2008 changes relative to FY 2007. The average increase for all
hospitals is approximately 4.3 percent. This is a 0.6 percent increase
in expected payments compared to the 3.7 percent average increase to
all hospitals published in the second FY 2008 IPPS correction notice.
This estimated increase in payments can be attributed to the
statutorily mandated change in the documentation and coding adjustment
to the standardized amounts from -1.2 percent to -0.6 percent. As shown
in table 1, columns 3a and 3b, most classes of hospitals are estimated
to experience an additional 0.6 percent increase in payments in FY 2008
compared with our previously published estimates with the increases
shown in the table sometimes appearing to be slightly more (0.7
percentage points) due to rounding. As noted previously, as a result of
the combination of the law change and a policy change to not apply the
documentation and coding adjustment to the hospital-specific rates for
MDHs and SCHs, certain categories of hospitals (MDHs, SCHs, rural
hospitals, and certain rural geographic areas with relatively large
numbers of SCHs and MDHs) are estimated to experience an increase in
their operating payments of slightly more than 0.6 percentage points
compared with the policies articulated in the FY 2008 IPPS final rule.
However, column 3b shows an increase in operating payments for these
categories of hospitals of only about 0.1 to 0.5 percentage points
greater than our previously published impact estimates in column 3a
(rather than more than 0.6 percentage points) due to a technical error
in our previously published impact estimates that had overstated the FY
2008 increase in payments to these hospitals.
6. Overall Conclusion
The IPPS changes we are making in this final rule will affect all
classes of hospitals. All classes of hospitals are expected to
experience increases in their FY 2008 IPPS payments as a result of the
provisions of this final rule. Table I of this section demonstrates the
statutorily mandated change to the documentation and coding adjustment
applied to the standardized amount, the policy change of the
nonapplication of the documentation and coding adjustment to the
hospital-specific rate and all other policies reflected in the FY 2008
IPPS final rule. Table I also shows an overall increase of 4.3 percent
in operating payments, an estimated increase of $4.29 billion, which
includes hospital reporting of quality data program costs ($1.89
million) and all operating payment policies as described in this
section XXIV.G. Capital payments are estimated to increase by 1.2
percent per case from FY 2007 to FY 2008. The average increase in FY
2008 capital IPPS payments for all hospitals is approximately 0.6
percentage points higher than in the second FY 2008 IPPS correction
notice, as expected based on the statutorily mandated change in the FY
2008 documentation and coding adjustment from -1.2 percent to -0.6
percent. Therefore, we project that capital payments will increase by
$342 million in FY 2008 compared to FY 2007. The operating and capital
payments should result in a net increase of $4.635 billion to IPPS
providers. This is an additional increase in estimated payments by $665
million compared to the estimated increase in payments published in the
second FY 2008 IPPS correction notice. The discussions presented in the
previous subsections, in combination with section XIX. of this final
rule, constitute a regulatory impact analysis.
7. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehousegov/omb/circulars/a004/a-4.pdf), in Table II below, we
have prepared an accounting statement showing the classification of the
expenditures associated with the IPPS provisions of this final rule.
This table provides our best estimate of the increase in Medicare
payments to providers from FY 2007 to FY 2008 as a result of the IPPS
policies established in the FY 2008 IPPS final rule and in section XIX.
of this final rule. All expenditures are classified as transfers to
Medicare providers.
Table II.--Accounting Statement: Classification of Estimated
Expenditures From FY 2007 to FY 2008
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............ $4.635 Billion.
From Whom to Whom......................... Federal Government to IPPS
Medicare Providers.
-----------------------------
Total................................. $4.635 Billion.
------------------------------------------------------------------------
8. Executive Order 12866
In accordance with the provisions of Executive Order 12866, this
final rule was reviewed by the Office of Management and Budget.
H. Impact of the Policy Revisions Related to Emergency Medicare GME
Affiliated Groups for Hospitals in Certain Declared Emergency Areas
As we discussed in detail in section XX. of this document, we are
issuing an interim final rule with comment period that modifies the
current GME regulations as they apply to emergency Medicare GME
affiliated groups to provide for greater flexibility in training
residents in approved residency programs during times of disaster.
[[Page 66928]]
Specifically, the interim final rule with comment period modifies
provisions for ``emergency Medicare GME affiliated groups'' to address
the needs of teaching hospitals that are forced to find alternate
training sites for residents that were displaced by a disaster.
1. Overall Impact
This interim final rule with comment period rule is not a major
rule under Executive Order 12866 because we anticipate that the cost to
the Medicare program will be negligible under the provisions included
in this rule.
2. RFA
For purposes of the RFA, we believe that the impact on the affected
hospitals will not be significant and will not affect a substantial
number of small entities.
3. Small Rural Hospitals
For purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 100 beds. This interim final rule
with comment period is not anticipated to have a significant effect on
small rural hospitals because the provisions of this interim final rule
with comment period are most likely to be used by large teaching
hospitals that have established residency programs and the capacity to
train a larger complement of displaced residents. The majority of this
type of teaching hospital is located in non-rural areas.
4. Unfunded Mandates
Section 202 of the Unfunded Mandates Reform Act of 1995 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. This interim final rule with
comment period will not have an effect on State, local, or tribal
governments in the aggregate and the private sector costs will be less
than the $120 million threshold.
5. Federalism
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. This interim final rule with comment period will not have
a substantial effect on State or local governments.
6. Anticipated Effects
We believe that there are limited effects associated with modifying
the existing emergency Medicare GME affiliation regulations to extend
the effective period as well as to permit certain written agreements
for training that occurs in the nonhospital setting to be submitted
retroactively. We note that these changes do not allow hospitals to
count for Medicare IME or direct GME payment purposes additional FTE
residents that had not been counted by Medicare before a qualifying
emergency. Hospitals participating in emergency Medicare GME affiliated
groups are held to their respective FTE resident caps as specified by
the emergency affiliation agreement. IME and direct GME payments to the
hospitals under this provision will not be based upon any FTE residents
in excess of the caps specified under the emergency Medicare GME
affiliation agreements.
7. Alternatives Considered
We considered making no changes at this time to the existing
emergency Medicare GME affiliation provisions. However, teaching
hospitals affected by Hurricanes Katrina and Rita have reported to us
that they are still experiencing difficulties in reestablishing their
training programs and they have requested the extension of the
effective period for emergency Medicare GME affiliation agreements to
continue beyond June 30, 2008. We understand that GME programs in the
affected area are finding it necessary to continue to adjust the
location of resident training both within the emergency area and in
other States, as affected hospitals in the section 1135 emergency area
continue to reopen beds at different rates, and as feedback from
accreditation surveys warrant educational adjustments. Extending the
effective period of emergency Medicare GME affiliation agreements for
two more academic years (for a total effective period of up to 5
academic years) would allow these hospitals the time to stabilize their
training programs. Furthermore, we considered the option of extending
the effective period for emergency Medicare GME affiliations for two
additional academic years without limiting the out of State emergency
affiliations to apply to only the residents that were immediately
displaced following the disaster. However, we ultimately specified that
in the additional 2 years, only the residents that were immediately
displaced following the disaster would be eligible to participate in
out of State emergency affiliations while residents that entered the
program after the disaster occurred would be limited to in State
emergency affiliations. We believe that the policy established in this
interim final rule with comment period extends additional flexibility
while providing an incentive for home hospitals to bring displaced
residents back to train in the State in which the home hospital is
located, increasing the probability that the physicians would stay and
practice locally after their training is completed. In addition, we
believe that providing for flexibility in submitting written agreements
after residents begin training in the nonhospital sites for hospitals
participating in emergency Medicare GME affiliation agreements
alleviates an additional deadline burden and allows appropriate GME
payments to be made to those hospitals that are facing financial and
programmatic hardships due to a disaster. We believe failure to apply
the regulatory changes in this interim final rule with comment would be
contrary to the public interest because hospitals affected by
Hurricanes Katrina and Rita could otherwise face dramatic disruptions
in their Medicare GME funding, with possible dire effects on their GME
programs and financial stability.
8. Conclusion
For these reasons, we are not preparing analyses for either the RFA
or section 1102(b) of the Act because we have determined that this
interim final rule with comment period would not have a significant
economic impact on a substantial number of small entities or a
significant impact on the operations of a substantial number of small
rural hospitals.
9. Executive Order 12866
In accordance with the provisions of Executive Order 12866, this
interim final rule with comment period was reviewed by the Office of
Management and Budget.
XXV. Waiver of Proposed Rulemaking, Waiver of Delay in Effective Date,
and Retroactive Effective Date
A. Requirements for Waivers and Retroactive Rulemaking
We ordinarily publish a notice of proposed rulemaking in the
Federal Register to provide for public comment before the provisions of
a rule take effect in accordance with section 553(b) of the
Administrative Procedure Act (APA). However, we can waive notice-and-
comment procedures if the Secretary finds, for good cause, that the
notice-and-comment process is impracticable,
[[Page 66929]]
unnecessary, or contrary to the public interest, and incorporates a
statement of the finding and the reasons therefore in the rule. Section
553(d) of the APA also ordinarily requires a 30-day delay in effective
date of final rules after the date of their publication. However, this
30-day delay in effective date can be waived if an agency finds for
good cause that the delay is impracticable, unnecessary, or contrary to
the public interest, and the agency incorporates a statement of the
findings and its reasons in the rule issued. Moreover, section
1871(e)(1)(A) of the Act generally prohibits the Secretary from making
retroactive substantive changes in policy unless retroactive
application of the change is necessary to comply with statutory
requirements or failure to apply the change retroactively would be
contrary to the public interest.
B. IPPS Payment Rate Policies
We are waiving notice-and-comment procedures and the 30-day delay
in effective date with respect to the revised payment factors, rates,
and thresholds discussed in section XIX.B.1. of this final rule. In
section XIX.B.1. of this final rule, we are revising certain payment
factors, rates, and thresholds under the IPPS to reflect the changes to
the documentation and coding adjustment mandated under section 7 of
Public Law 110-90. The policies adopted in the FY 2008 IPPS final rule
were subjected to notice-and-comment procedures. The payment factors,
rates, and thresholds discussed in section XIX.B.1. of this final rule
reflect the payment policies adopted in the FY 2008 IPPS final rule,
but have been recalculated using the reduced coding and documentation
adjustment to the standardized amounts. Therefore, we find that it
would be unnecessary and contrary to the public interest to delay
correction of payment factors and rates under the IPPS by undertaking
further notice-and-comment procedures. For the same reasons, we are
also waiving the 30-day delay in effective date with respect to the
revised payment factors, rates, and thresholds discussed in section
XIX.B.1. of this final rule. We believe that it is in the public
interest to ensure that these revised payment factors, rates, and
thresholds are effective as of the October 1, 2007 effective date of
the FY 2008 IPPS final rule.
The revised payment factors, rates, and thresholds discussed in
section XIX.B.1. of this final rule do not substantively change
policies adopted in the FY 2008 IPPS final rule. Under section 7 of
Public Law 110-90, we are required to reduce the documentation and
coding adjustment that we adopted in the FY 2008 IPPS final rule and,
as a result, the standardized amounts for FY 2008 will be higher. In
section XIX.B.1. of this final rule, we merely are announcing new
payment factors, rates, and thresholds that result from applying the
statutorily mandated documentation and coding adjustment pf -0.6
percent to the payment policies we adopted in the FY 2008 IPPS final
rule. Therefore, we do not believe these changes implicate section
1871(e)(1)(A) of the Act.
With respect to the application of the documentation and coding
adjustment to hospital-specific rates discussed in section XIX.B.2. of
this final rule, we are waiving notice-and-comment procedures, the 30-
day delay in effective date, and making a retroactive substantive
change to a policy adopted in the FY 2008 IPPS final rule. As discussed
in section XIX.B.2. of this final rule, we believe that the policy we
adopted in the FY 2008 IPPS final rule was not consistent with the
plain meaning of section 1886(d)(3)(A)(vi) of the Act. Therefore, we
are waiving notice-and-comment procedures with respect to this policy
change because we believe it would be unnecessary and contrary to the
public interest to undertake notice-and-comment procedures prior to
changing our policy to make the policy consistent with the plain
meaning of the statute. For the same reasons, we are waiving the 30-day
delay in effective date because we believe it would be unnecessary and
contrary to the public interest to delay the policy change beyond the
October 1, 2007 effective date of the FY 2008 IPPS final rule. We are
also applying this policy change retroactive to October 1, 2007 under
section 1871(e)(1)(A)(i) of the Act because it would be contrary to the
public interest for our policy not to be consistent with the plain
meaning of the statute. Furthermore, because an adjustment to the
hospital-specific rates to account for changes in documentation and
coding is not authorized under section 1886(d)(3)(A)(vi) of the Act,
retroactive application of this change is necessary to comply with the
statute.
C. Medicare GME Affiliation Agreement Provisions
We find that failure to apply the provisions of this interim final
rule with comment period retroactively to August 29, 2005, which is the
first date on which there was an emergency area and emergency period
under section 1135 of the Act resulting from the impact of Hurricane
Katrina, would be contrary to the public interest. Due to the
infrastructure damage and disruption of operations experienced by
medical facilities, and the consequent and continuing disruption in
residency training, caused by Hurricanes Katrina and Rita in August of
2005, there is an urgent need for the regulation changes provided in
this interim final rule with comment period to be applied
retroactively. The existing regulations specify that the effective
period for emergency Medicare GME affiliation agreements must end no
later than June 30, 2008, even though many hospitals within the section
1135 emergency area have not fully recovered from the disruption caused
by Hurricanes Katrina and Rita. Hospitals have informed CMS that it is
critical for the permissible effective period for emergency Medicare
GME affiliation agreements to be extended because the current
regulations do not adequately address the continuing issues relating to
Medicare GME payment policy faced by both home and host hospitals.
Specifically, where home or host hospitals with valid emergency
Medicare GME affiliation agreements have been training displaced
residents in non-hospital sites at any time since August 29, 2005, the
provisions in this interim final rule with comment period allow these
home or host hospitals to submit written agreements or incur all or
substantially all of the costs of the program at the nonhospital site
retroactive to that date in order to permit the home or host hospitals
to count the FTE residents training in non-hospital sites for direct
GME and IME payment purposes. We believe failure to apply the
regulatory changes contained in this interim final rule with comment
period retroactively would be contrary to the public interest because
hospitals whose graduate medical education programs were affected by
Hurricanes Katrina and Rita could otherwise face dramatic disruptions
in their Medicare GME funding, with possible dire effects on the
residency training programs and financial stability of the hospitals,
and possible adverse consequences for the Medicare program in terms of
access to hospital and physician health care resources.
Furthermore, the training programs at many teaching hospitals in
New Orleans and surrounding areas were temporarily closed or
significantly reduced in the aftermath of the hurricanes, and the
displaced residents were transferred to other hospitals to continue
their training programs in other parts of the country. While some
residents have returned to the hurricane-affected hospitals, others
remain displaced from their home
[[Page 66930]]
hospitals to hospitals located out-of-state. Immediate regulatory
changes are required in order to maintain Medicare GME funding relating
to displaced residents training at various hospitals outside of the
emergency area, and at the same time, to encourage re-establishment of
residency training within the hurricane-affected State, and to assist
home hospitals to rebuild incrementally their GME programs. Existing
regulations relating to closed hospitals and closed residency training
programs, and relating to regular and emergency Medicare GME
affiliation agreements, as well as to residency training that occurs in
non-hospital settings, contain certain limitations that render them
inapplicable or ineffective to address the issues faced by hospitals as
a result of disruptions caused by Hurricanes Katrina and Rita.
We also ordinarily publish a notice of proposed rulemaking in the
Federal Register and invite public comment on the proposed rule. The
notice of proposed rulemaking includes a reference to the legal
authority under which the rule is proposed, and the terms and substance
of the proposed rule or a description of the subjects and issues
involved. However, this procedure can be waived if an agency finds good
cause that a notice-and-comment procedure is impracticable, unnecessary
or contrary to the public interest and incorporates a statement of the
finding and supporting reasons in the rule issued. We find that good
cause exists to waive the requirement for publication of a notice of
proposed rulemaking and public comment prior to the effective date of
this rule because such a procedure would be impracticable and contrary
to the public interest. As explained above, in order to respond to the
urgent needs of the hospitals and GME programs affected by Hurricanes
Katrina and Rita, particularly in the provision regarding the
retroactive submission of written agreements or payment of all or
substantially all of the costs of the program at the non-hospital site
to allow hospitals that have been training residents in non-hospital
sites since the first day of the section 1135 emergency period relating
to Hurricanes Katrina and Rita on August 29, 2005, it is necessary for
the regulation to take effect retroactively to August 29, 2005.
Furthermore, as hospitals engage in planning for the training of
residents in programs for the upcoming academic year which begins on
July 1, 2008, hospitals need adequate time to arrange emergency
Medicare GME affiliation agreements with respect to remaining displaced
residents training at host hospitals. The ordinary notice-and-comment
procedures would serve to delay (or, in certain cases, preclude)
hurricane-affected hospitals and GME programs from responding
effectively to their circumstances by availing themselves of the
flexibility permitted under this interim final rule with comment
period.
List of Subjects
42 CFR Part 410
Health facilities, Health professions, Laboratories, Medicare,
Rural areas, X rays
42 CFR Part 411
Kidney diseases, Medicare, Physician referral, Reporting and
recordkeeping requirements
42 CFR Part 413
Health facilities, Kidney diseases, Medicare, Puerto Rico,
Reporting and recordkeeping requirements.
42 CFR Part 414
Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medicare, Reporting and recordkeeping
requirements
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 482
Grant program-health, Hospitals, Medicaid, Medicare, Reporting and
recordkeeping requirements
42 CFR Part 485
Grant program-health, Health facilities, Medicaid, 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 410.27 is amended by--
0
a. Revising paragraph (a)(1)(iii).
0
b. Revising paragraph (f).
The revisions read as follows:
Sec. 410.27 Outpatient hospital services and supplies incident to a
physician service: Conditions.
(a) * * *
(1) * * *
(iii) In the hospital or at a department of a provider, as defined
in Sec. 413.65(a)(2) of this subchapter, that has provider-based
status in relation to a hospital under Sec. 413.65 of this subchapter;
and
* * * * *
(f) Services furnished at a department of a provider, as defined in
Sec. 413.65(a)(2) of this subchapter, that has provider-based status
in relation to a hospital under Sec. 413.65 of this subchapter, must
be under the direct supervision of a physician. ``Direct supervision''
means the physician must be present and on the premises of the location
and immediately available to furnish assistance and direction
throughout the performance of the procedure. It does not mean that the
physician must be present in the room when the procedure is performed.
PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE
PAYMENT
0
3. The authority citation for Part 411 continues to read as follows:
Authority: Secs. 1102, 1860D-1 through 1860D-42, 1871, and 1877
of the Social Security Act (42 U.S.C. 1302, 1395w-101 through 1395w-
152, and 1395nn.
0
4. Section 411.351 is amended by revising paragraph (2) of the
definition of ``designated health services'' and the definitions of
``outpatient prescription drugs'' and ``radiology and certain other
imaging services'' to read as follows:
Sec. 411.351 Definitions.
* * * * *
Designated health services (DHS) means * * *
(2) Except as otherwise noted in this subpart, the term
``designated health services'' or DHS means only DHS payable, in whole
or in part, by Medicare. DHS do not include services that are
reimbursed by Medicare as part of a composite rate (for example, SNF
Part A payments or ASC services identified at Sec. 416.164(a)), except
to the extent that services listed in paragraphs (1)(i) through (1)(x)
of this definition are themselves payable through a composite rate (for
example, all services provided as home health services or inpatient and
outpatient hospital services are DHS).
* * * * *
[[Page 66931]]
Outpatient prescription drugs means all drugs covered by Medicare
Part B or D, except for those drugs that are ``covered ancillary
services,'' as defined at Sec. 416.164(b) of this chapter, for which
separate payment is made to an ambulatory surgical center.
* * * * *
Radiology and certain other imaging services means those particular
services so identified on the List of CPT/HCPCS Codes. All services
identified on the List
of CPT/HCPCS Codes are radiology and certain other imaging services for
purposes of this subpart. Any service not specifically identified as
radiology and certain other imaging services on the List of CPT/HCPCS
Codes is not a radiology or certain other imaging service for purposes
of this subpart. The list of codes identifying radiology and certain
other imaging services includes the professional and technical
components of any diagnostic test or procedure using x-rays,
ultrasound, computerized axial tomography, magnetic resonance imaging,
nuclear medicine (effective January 1, 2007), or other imaging
services. All codes identified as radiology and certain other imaging
services are covered under section 1861(s)(3) of the Act and Sec.
410.32 and Sec. 410.34 of this chapter, but do not include--
(1) X-ray, fluoroscopy, or ultrasound procedures that require the
insertion of a needle, catheter, tube, or probe through the skin or
into a body orifice;
(2) Radiology or certain other imaging services that are integral
to the performance of a medical procedure that is not identified on the
list of CPT/HCPCS codes as a radiology or certain other imaging service
and is performed--
(i) Immediately prior to or during the medical procedure; or
(ii) Immediately following the medical procedure when necessary to
confirm placement of an item placed during the medical procedure.
(3) Radiology and certain other imaging services that are ``covered
ancillary services,'' as defined at Sec. 416.164(b), for which
separate payment is made to an ASC.
* * * * *
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR
END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT
RATES FOR SKILLED NURSING FACILITIES
0
5. The authority citation for Part 413 is revised to read as follows:
Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and
(n), 1861(v), 1871, 1881, 1883, and 1886 of the Social Security Act
(42 U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n),
1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww); and sec. 124 of
Public Law 106-133 (113 Stat. 1501A-332).
0
6. Section 413.75(b) is amended by revising paragraph (2) under the
definition of ``Emergency Medicare GME affiliated group'' to read as
follows:
Sec. 413.75 Direct GME payments: General requirements.
* * * * *
(b) * * *
Emergency Medicare GME affiliated group * * *
(2) Host hospital means a hospital training residents displaced
from a home hospital.
(a) In-State host hospital means a host hospital located in the
same State as a home hospital.
(b) Out-of-State host hospital means a host hospital located in a
different State from the home hospital.
* * * * *
0
7. Section 413.78 is amended by--
0
a. Removing the semicolon and the word ``or'' at the end of paragraph
(e)(3)(i) and replacing them with a period.
0
b. Adding a new paragraph (e)(3)(iii).
0
c. Removing the semicolon and the word ``or'' at the end of paragraph
(f)(3)(i) and replacing them with a period.
0
d. Adding a new paragraph (f)(3)(iii).
The additions read as follows:
Sec. 413.78 Direct GME payments: Determination of the total number of
FTE residents.
* * * * *
(e) * * *
(3) * * *
(iii) If the hospital has in place an emergency Medicare GME
affiliation agreement in accordance with Sec. 413.79(f)(6), during the
period covered by the emergency Medicare GME affiliation agreement--
(A) The hospital must pay all or substantially all of the costs of
the training program in a nonhospital setting(s) attributable to
training that occurs during a month by the end of the sixth month
following the month in which the training in the nonhospital site
occurred. For the costs that would otherwise be required to be paid by
the hospital during the period of August 29, 2005 through November 1,
2007, the participating hospital must pay the costs by April 29, 2008;
or
(B) There is a written agreement that specifies that the hospital
is incurring the cost of the resident's salary and fringe benefits
while the resident is training in the nonhospital site and the hospital
is providing reasonable compensation to the nonhospital site for
supervisory teaching activities. The agreement must indicate the
compensation the hospital is providing to the nonhospital site for
supervisory teaching activities. The written agreement must be
submitted to the contractor by 180 days after the training at the
nonhospital site begins. For written agreements that would otherwise be
required to be submitted prior to the date the resident(s) begin
training at the nonhospital site during the period of August 29, 2005
through November 1, 2007, the written agreement must be submitted to
the CMS contractor by April 29, 2008.
* * * * *
(f) * * *
(3) * * *
(iii) If the hospital has in place an emergency Medicare GME
affiliation agreement in accordance with Sec. 413.79(f)(6), during the
period covered by the emergency Medicare GME affiliation agreement--
(A) The hospital must pay all or substantially all of the costs of
the training program in a nonhospital setting(s) attributable to
training that occurs during a month by the end of the sixth month after
the month in which the training in the nonhospital site occurs. For the
costs that would otherwise be required to be incurred by the hospital
during the period of August 29, 2005 through November 1, 2007, the
participating hospital must incur the costs by April 29, 2008; or
(B) There is a written agreement that specifies that the hospital
will incur at least 90 percent of the total of the costs of the
resident's salary and fringe benefits (and travel and lodging where
applicable) while the resident is training in the nonhospital site and
the portion of the cost of the teaching physician's salary attributable
to nonpatient care direct GME activities. The written agreement must
specify the total cost of the training program at the nonhospital site,
and the amount the hospital will incur (at least 90 percent of the
total), and must indicate the portion of the amount the hospital will
incur that reflects residents' salaries and fringe benefits (and travel
and lodging where applicable), and the portion of this amount that
reflects teaching physician compensation. The written agreement must be
submitted to the contractor by 180 days after the training at the
nonhospital site begins. Hospitals may modify the amounts specified in
the
[[Page 66932]]
written agreement by the end of the academic year (that is, June 30) to
reflect that at least 90 percent of the costs of the training program
in the nonhospital site has been incurred. For written agreements that
would otherwise be required to be submitted prior to the date the
training begins in the nonhospital site during the period of August 29,
2005 through November 1, 2007, the hospital must submit the written
agreement to its contractor by April 29, 2008.
* * * * *
0
8. Section 413.79 is amended by--
0
a. Revising the introductory text of paragraph (f)(6).
0
b. Revising paragraph (f)(6)(i)(D).
0
c. Revising paragraph (f)(6)(ii)(A)(2).
The revisions read as follows:
Sec. 413.79 Direct GME payments: Determination of the weighted number
of FTE residents.
* * * * *
(f) * * *
(6) Emergency Medicare GME affiliated group. Effective on or after
August 29, 2005, home and host hospitals as defined in Sec. 413.75(b)
may form an emergency Medicare GME affiliated group by meeting the
requirements provided in this section. The emergency Medicare GME
affiliation agreements may be made effective beginning on or after the
first day of a section 1135 emergency period, and must terminate no
later than at the conclusion of 4 academic years following the academic
year during which the section 1135 emergency period began.
* * * * *
(i) * * *
(D) Specify the total adjustment to each participating hospital's
FTE caps in each academic year that the emergency Medicare GME
affiliation agreement is in effect, for both direct GME and IME, that
reflects a positive adjustment to the host hospital's direct and
indirect FTE caps that is offset by a negative adjustment to the home
hospital's (or hospitals') direct and indirect FTE caps of at least the
same amount subject to the following--
(1) The sum total of adjustments to all the participating
hospitals' FTE caps under the emergency Medicare GME affiliation
agreement may not exceed the aggregate adjusted FTE caps of the
hospitals participating in the emergency Medicare GME affiliated group.
(2) A home hospital's IME and direct GME FTE cap reductions in an
emergency Medicare GME affiliation agreement are limited to the home
hospital's IME and direct GME FTE resident caps at Sec. 413.79(c) or
Sec. 413.79(f)(1) through (f)(5), that is, as adjusted by any and all
existing affiliation agreements as applicable.
(3) For emergency Medicare GME affiliation agreements for the third
or fourth academic years subsequent to the year in which the section
1135 emergency period began and involving an out-of-State host
hospital, the positive adjustment to the out-of-State host hospital's
direct and indirect FTE caps pursuant to the agreement shall reflect
only FTE residents that were actually displaced from a home hospital
immediately following the emergency.
* * * * *
(ii) * * *
(A) * * *
(2) Four subsequent academic years. The later of 180 days after the
section 1135 emergency period begins, or by July 1 of each academic
year for 4 subsequent years.
* * * * *
PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
0
9. The authority citation for Part 414 continues to read as follows:
Authority: Secs. 1102, 1871, and 1881(b)(1) of the Social
Security Act (42 U.S.C. 1302, 1395hh, and 1395rr(b)(1)).
0
10. Section 414.22 is amended by revising paragraphs (b)(5)(i)(A) and
(B) to read as follows:
Sec. 414.22 Relative value units (RVUs).
* * * * *
(b) * * *
(5) * * *
(i) * * *
(A) Facility practice expense RVUs. The lower facility practice
expense RVUs apply to services furnished to patients in the hospital,
skilled nursing facility, community mental health center, or in an
ambulatory surgical center. (The facility practice expense RVUs for a
particular code may not be greater than the nonfacility RVUs for the
code.)
(B) Nonfacility practice expense RVUs. The higher nonfacility
practice expense RVUs apply to services performed in a physician's
office, a patient's home, a nursing facility, or a facility or
institution other than a hospital or skilled nursing facility,
community mental health center, or ASC.
* * * * *
PART 416--AMBULATORY SURGICAL SERVICES
0
11. 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
12. Section 416.179 is amended by--
0
a. Revising the section heading.
0
b. Revising paragraphs (a)(1) and (a)(2).
0
c. Adding new paragraph (a)(3).
0
d. Revising paragraph (b).
The revisions and additions read as follows:
Sec. 416.179 Payment and coinsurance reduction for devices replaced
without cost or when full or partial credit is received.
(a) * * *
(1) The device is replaced without cost to the ASC or the
beneficiary;
(2) The ASC receives full credit for the cost of a replaced device;
or
(3) The ASC receives partial credit for the cost of a replaced
device but only where the amount of the device credit is greater than
or equal to 50 percent of the cost of the new replacement device being
implanted.
(b) Amount of reduction to the ASC payment for the covered surgical
procedure.
(1) The amount of the reduction to the ASC payment made under
paragraphs (a)(1) and (a)(2) of this section is calculated in the same
manner as the device payment reduction that would be applied to the ASC
payment for the covered surgical procedure in order to remove
predecessor device costs so that the ASC payment amount for a device
with pass-through status under Sec. 419.66 of this subchapter
represents the full cost of the device, and no packaged device payment
is provided through the ASC payment for the covered surgical procedure.
(2) The amount of the reduction to the ASC payment made under
paragraph (a)(3) of this section is 50 percent of the payment reduction
that would be calculated under paragraph (b)(1) of this section.
* * * * *
PART 419--PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT
DEPARTMENT SERVICES
0
13. 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
14. Section 419.43 is amended by revising paragraph (g)(4) to read as
follows:
[[Page 66933]]
Sec. 419.43 Adjustments to national program payment and beneficiary
copayment amounts.
* * * * *
(g) * * *
(4) Excluded services and groups. Drugs and biologicals that are
paid under a separate APC and devices paid under Sec. 419.66 are
excluded from qualification for the payment adjustment in paragraph
(g)(2) of this section.
* * * * *
0
15. Section 419.44 is amended by--
0
a. Revising the section heading.
0
b. Revising paragraph (b).
The revisions and addition read as follows:
Sec. 419.44 Payment reductions for procedures.
* * * * *
(b) Interrupted procedures. When a procedure is terminated prior to
completion due to extenuating circumstances or circumstances that
threaten the well-being of the patient, the Medicare program payment
amount and the beneficiary copayment amount are based on--
(1) The full program and beneficiary copayment amounts if the
procedure for which anesthesia is planned is discontinued after the
induction of anesthesia or after the procedure is started;
(2) One-half the full program and the beneficiary copayment amounts
if the procedure for which anesthesia is planned is discontinued after
the patient is prepared and taken to the room where the procedure is to
be performed but before anesthesia is induced; or
(3) One-half of the full program and beneficiary copayment amounts
if a procedure for which anesthesia is not planned is discontinued
after the patient is prepared and taken to the room where the procedure
is to be performed.
0
16. Section 419.45 is amended by--
0
a. Revising the section heading.
0
b. Revising paragraph (a)(1).
0
c. Revising paragraph (a)(2).
0
d. Adding new paragraph (a)(3).
0
e. Revising paragraph (b).
The revisions and additions read as follows:
Sec. 419.45 Payment and copayment reduction for devices replaced
without cost or when full or partial credit is received.
(a) * * *
(1) The device is replaced without cost to the provider or the
beneficiary;
(2) The provider receives full credit for the cost of a replaced
device; or
(3) The provider receives partial credit for the cost of a replaced
device but only where the amount of the device credit is greater than
or equal to 50 percent of the cost of the new replacement device being
implanted.
(b) Amount of reduction to the APC payment.
(1) The amount of the reduction to the APC payment made under
paragraphs (a)(1) and (a)(2) of this section is calculated in the same
manner as the offset amount that would be applied if the device
implanted during a procedure assigned to the APC had transitional pass-
through status under Sec. 419.66.
(2) The amount of the reduction to the APC payment made under
paragraph (a)(3) of this section is 50 percent of the offset amount
that would be applied if the device implanted during a procedure
assigned to the APC had transitional pass-through status under Sec.
419.66.
* * * * *
Sec. 419.70 [Amended]
0
17. Section 419.70 is amended by--
0
a. In paragraph (d)(1)(i), removing the cross-reference ``Sec.
412.63(b)'' and adding the cross-reference ``Sec. 412.64(b)'' in its
place.
0
b. In paragraph (d)(2)(i), removing the cross-reference ``Sec.
412.63(b)'' and adding the cross-reference ``Sec. 412.64(b)'' in its
place.
0
c. In paragraph (d)(4)(ii), removing the cross-reference ``Sec.
412.63(b)'' and adding the phrase ``Sec. 412.63(b) or Sec. 412.64(b),
as applicable,'' in its place.
PART 482--CONDITIONS OF PARTICIPATION FOR HOSPITALS
0
18. The authority citation for Part 482 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
0
19. Section 482.22 is amended by revising paragraph (c)(5) to read as
follows:
Sec. 482.22 Condition of participation: Medical staff.
* * * * *
(c) * * *
(5) Include a requirement that--
(i) A medical history and physical examination be completed and
documented for each patient no more than 30 days before or 24 hours
after admission or registration, but prior to surgery or a procedure
requiring anesthesia services. The medical history and physical
examination must be completed and documented by a physician (as defined
in section 1861(r) of the Act), an oromaxillofacial surgeon, or other
qualified licensed individual in accordance with State law and hospital
policy.
(ii) An updated examination of the patient, including any changes
in the patient's condition, be completed and documented within 24 hours
after admission or registration, but prior to surgery or a procedure
requiring anesthesia services, when the medical history and physical
examination are completed within 30 days before admission or
registration. The updated examination of the patient, including any
changes in the patient's condition, must be completed and documented by
a physician (as defined in section 1861(r) of the Act), an
oromaxillofacial surgeon, or other qualified licensed individual in
accordance with State law and hospital policy.
* * * * *
Sec. 482.23 [Amended]
0
20. In Sec. 482.23(b)(1), the cross-reference ``Sec. 405.1910(c)'' is
removed and the cross-reference ``Sec. 488.54(c)'' is added in its
place.
0
21. Section 482.24 is amended by revising paragraph (c)(2)(i) to read
as follows:
Sec. 482.24 Condition of participation: Medical record services.
* * * * *
(c) * * *
(2) * * *
(i) Evidence of--
(A) A medical history and physical examination completed and
documented no more than 30 days before or 24 hours after admission or
registration, but prior to surgery or a procedure requiring anesthesia
services. The medical history and physical examination must be placed
in the patient's medical record within 24 hours after admission or
registration, but prior to surgery or a procedure requiring anesthesia
services.
(B) An updated examination of the patient, including any changes in
the patient's condition, when the medical history and physical
examination are completed within 30 days before admission or
registration. Documentation of the updated examination must be placed
in the patient's medical record within 24 hours after admission or
registration, but prior to surgery or a procedure requiring anesthesia
services.
* * * * *
0
22. Section 482.51 is amended by revising paragraph (b)(1) to read as
follows:
Sec. 482.51 Condition of participation: Surgical services.
* * * * *
[[Page 66934]]
(b) * * *
(1) Prior to surgery or a procedure requiring anesthesia services
and except in the case of emergencies:
(i) A medical history and physical examination must be completed
and documented no more than 30 days before or 24 hours after admission
or registration.
(ii) An updated examination of the patient, including any changes
in the patient's condition, must be completed and documented within 24
hours after admission or registration when the medical history and
physical examination are completed within 30 days before admission or
registration.
* * * * *
0
23. Section 482.52 is amended by--
0
a. Revising paragraph (b)(1).
0
b. Revising paragraph (b)(3).
0
c. Removing paragraph (b)(4).
The revisions read as follows:
Sec. 482.52 Condition of participation: Anesthesia services.
* * * * *
(b) * * *
(1) A preanesthesia evaluation completed and documented by an
individual qualified to administer anesthesia, as specified in
paragraph (a) of this section, performed within 48 hours prior to
surgery or a procedure requiring anesthesia services.
* * * * *
(3) A postanesthesia evaluation completed and documented by an
individual qualified to administer anesthesia, as specified in
paragraph (a) of this section, no later than 48 hours after surgery or
a procedure requiring anesthesia services. The postanesthesia
evaluation for anesthesia recovery must be completed in accordance with
State law and with hospital policies and procedures that have been
approved by the medical staff and that reflect current standards of
anesthesia care.
* * * * *
PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS
0
24. 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
25. Section 485.610 is amended by adding new paragraph (e) to read as
follows:
Sec. 485.610 Condition of participation: Status and location.
* * * * *
(e) Standard: Off-campus and co-location requirements for CAHs. A
CAH may continue to meet the location requirement of paragraph (c) of
this section based only if the CAH meets the following:
(1) If a CAH with a necessary provider designation is co-located
(that is, it shares a campus, as defined in Sec. 413.65(a)(2) of this
chapter, with another hospital or CAH), the necessary provider CAH can
continue to meet the location requirement of paragraph (c) of this
section only if the co-location arrangement was in effect before
January 1, 2008, and the type and scope of services offered by the
facility co-located with the necessary provider CAH do not change. A
change of ownership of any of the facilities with a co-location
arrangement that was in effect before January 1, 2008, will not be
considered to be a new co-location arrangement.
(2) If a CAH or a necessary provider CAH operates an off-campus
provider-based location, excluding an RHC as defined in Sec.
405.2401(b) of this chapter, but including a department or remote
location, as defined in Sec. 413.65(a)(2) of this chapter, or an off-
campus distinct part psychiatric or rehabilitation unit, as defined in
Sec. 485.647, that was created or acquired by the CAH on or after
January 1, 2008, the CAH can continue to meet the location requirement
of paragraph (c) of this section only if the off-campus provider-based
location or off-campus distinct part unit is located more than a 35-
mile drive (or, in the case of mountainous terrain or in areas with
only secondary roads available, a 15-mile drive) from a hospital or
another CAH.
(3) If either a CAH or a CAH that has been designated as a
necessary provider by the State does not meet the requirements in
paragraph (e)(1) of this section, by co-locating with another hospital
or CAH on or after January 1, 2008, or creates or acquires an off-
campus provider-based location or off-campus distinct part unit on or
after January 1, 2008, that does not meet the requirements in paragraph
(e)(2) of this section, the CAH's provider agreement will be subject to
termination in accordance with the provisions of Sec. 489.53(a)(3) of
this subchapter, unless the CAH terminates the off-campus arrangement
or the co-location arrangement, or both.
Authority: (Catalog of Federal Domestic Assistance Program No.
93.773, Medicare--Hospital Insurance; and Program No. 93.774,
Medicare--Supplementary Medical Insurance Program).
(Catalog of Federal Domestic Assistance Program No. 93.778, Medical
Assistance Program)
Dated: October 25, 2007.
Kerry Weems,
Acting Administrator, Centers for Medicare & Medicaid Services.
Dated: October 30, 2007.
Michael O. Leavitt,
Secretary.
Addendum A.--OPPS APCS for CY 2008
----------------------------------------------------------------------------------------------------------------
National Minimum
APC Group title SI Relative Payment unadjusted unadjusted
weight rate copayment copayment
----------------------------------------------------------------------------------------------------------------
0001............. Level I S............... 0.4806 $30.61 $7.00 $6.12
Photochemotherapy.
0002............. Level I Fine Needle T............... 1.1097 $70.68 ........... $14.14
Biopsy/Aspiration.
0003............. Bone Marrow Biopsy/ T............... 3.1008 $197.50 ........... $39.50
Aspiration.
0004............. Level I Needle Biopsy/ T............... 4.3270 $275.60 ........... $55.12
Aspiration Except Bone
Marrow.
0005............. Level II Needle Biopsy/ T............... 7.1147 $453.16 ........... $90.63
Aspiration Except Bone
Marrow.
0006............. Level I Incision & T............... 1.4066 $89.59 ........... $17.92
Drainage.
0007............. Level II Incision & T............... 11.5594 $736.26 ........... $147.25
Drainage.
0008............. Level III Incision and T............... 18.3197 $1,166.85 ........... $233.37
Drainage.
0012............. Level I Debridement & T............... 0.2963 $18.87 ........... $3.77
Destruction.
0013............. Level II Debridement & T............... 0.7930 $50.51 ........... $10.10
Destruction.
0015............. Level III Debridement & T............... 1.4595 $92.96 ........... $18.59
Destruction.
0016............. Level IV Debridement & T............... 2.6604 $169.45 ........... $33.89
Destruction.
0017............. Level VI Debridement & T............... 19.9041 $1,267.77 ........... $253.55
Destruction.
0019............. Level I Excision/ T............... 4.3039 $274.13 $71.87 $54.83
Biopsy.
0020............. Level II Excision/ T............... 8.6850 $553.18 ........... $110.64
Biopsy.
0021............. Level III Excision/ T............... 16.1001 $1,025.48 $219.48 $205.10
Biopsy.
0022............. Level IV Excision/ T............... 21.1098 $1,344.57 $354.45 $268.91
Biopsy.
[[Page 66935]]
0023............. Exploration Penetrating T............... 9.6341 $613.63 ........... $122.73
Wound.
0028............. Level I Breast Surgery. T............... 20.6417 $1,314.75 $303.74 $262.95
0029............. Level II Breast Surgery T............... 31.7134 $2,019.95 $581.52 $403.99
0030............. Level III Breast T............... 39.8191 $2,536.24 $747.07 $507.25
Surgery.
0031............. Smoking Cessation X............... 0.1648 $10.50 ........... $2.10
Services.
0033............. Partial Hospitalization P............... 3.2211 $205.16 ........... $41.03
0034............. Mental Health Services P............... 3.2211 $205.16 ........... $41.03
Composite.
0035............. Arterial/Venous T............... 0.2143 $13.65 ........... $2.73
Puncture.
0037............. Level IV Needle Biopsy/ T............... 13.5764 $864.74 $228.76 $172.95
Aspiration Except Bone
Marrow.
0039............. Level I Implantation of S............... 186.4739 $11,877.27 ........... $2,375.45
Neurostimulator.
0040............. Percutaneous S............... 63.7866 $4,062.82 ........... $812.56
Implantation of
Neurostimulator
Electrodes, Excluding
Cranial Nerve.
0041............. Level I Arthroscopy.... T............... 28.7803 $1,833.13 ........... $366.63
0042............. Level II Arthroscopy... T............... 45.7072 $2,911.27 $804.74 $582.25
0043............. Closed Treatment T............... 1.7682 $112.62 ........... $22.52
Fracture Finger/Toe/
Trunk.
0045............. Bone/Joint Manipulation T............... 14.7658 $940.49 $268.47 $188.10
Under Anesthesia.
0047............. Arthroplasty without T............... 35.9040 $2,286.87 $537.03 $457.37
Prosthesis.
0048............. Level I Arthroplasty T............... 50.8876 $3,241.23 ........... $648.25
with Prosthesis.
0049............. Level I Musculoskeletal T............... 21.2689 $1,354.70 ........... $270.94
Procedures Except Hand
and Foot.
0050............. Level II T............... 29.1900 $1,859.23 ........... $371.85
Musculoskeletal
Procedures Except Hand
and Foot.
0051............. Level III T............... 42.9850 $2,737.89 ........... $547.58
Musculoskeletal
Procedures Except Hand
and Foot.
0052............. Level IV T............... 79.4244 $5,058.86 ........... $1,011.77
Musculoskeletal
Procedures Except Hand
and Foot.
0053............. Level I Hand T............... 16.4637 $1,048.64 $253.49 $209.73
Musculoskeletal
Procedures.
0054............. Level II Hand T............... 26.3105 $1,675.82 ........... $335.16
Musculoskeletal
Procedures.
0055............. Level I Foot T............... 20.8284 $1,326.64 $355.34 $265.33
Musculoskeletal
Procedures.
0056............. Level II Foot T............... 44.2687 $2,819.65 ........... $563.93
Musculoskeletal
Procedures.
0057............. Bunion Procedures...... T............... 29.4167 $1,873.67 $475.91 $374.73
0058............. Level I Strapping and S............... 1.0931 $69.62 ........... $13.92
Cast Application.
0060............. Manipulation Therapy... S............... 0.4482 $28.55 ........... $5.71
0061............. Laminectomy, S............... 82.8597 $5,277.67 ........... $1,055.53
Laparoscopy, or
Incision for
Implantation of
Neurostimulator
Electrodes, Excluding
Cranial Nerve.
0062............. Level I Treatment T............... 26.1592 $1,666.18 $372.87 $333.24
Fracture/Dislocation.
0063............. Level II Treatment T............... 41.1091 $2,618.40 $548.33 $523.68
Fracture/Dislocation.
0064............. Level III Treatment T............... 59.2233 $3,772.17 $835.79 $754.43
Fracture/Dislocation.
0065............. Level I Stereotactic S............... 16.5911 $1,056.75 ........... $211.35
Radiosurgery, MRgFUS,
and MEG.
0066............. Level II Stereotactic S............... 45.0693 $2,870.64 ........... $574.13
Radiosurgery, MRgFUS,
and MEG.
0067............. Level III Stereotactic S............... 61.6965 $3,929.70 ........... $785.94
Radiosurgery, MRgFUS,
and MEG.
0069............. Thoracoscopy........... T............... 32.5666 $2,074.30 $591.64 $414.86
0070............. Thoracentesis/Lavage T............... 5.2024 $331.36 ........... $66.27
Procedures.
0071............. Level I Endoscopy Upper T............... 0.8224 $52.38 $11.20 $10.48
Airway.
0072............. Level II Endoscopy T............... 1.6115 $102.64 $21.27 $20.53
Upper Airway.
0073............. Level III Endoscopy T............... 3.9940 $254.39 $69.15 $50.88
Upper Airway.
0074............. Level IV Endoscopy T............... 17.0160 $1,083.82 $292.25 $216.76
Upper Airway.
0075............. Level V Endoscopy Upper T............... 22.7191 $1,447.07 $445.92 $289.41
Airway.
0076............. Level I Endoscopy Lower T............... 9.9575 $634.23 $189.82 $126.85
Airway.
0077............. Level I Pulmonary S............... 0.3877 $24.69 $7.74 $4.94
Treatment.
0078............. Level II Pulmonary S............... 1.3362 $85.11 ........... $17.02
Treatment.
0079............. Ventilation Initiation S............... 2.4783 $157.85 ........... $31.57
and Management.
0080............. Diagnostic Cardiac T............... 38.9204 $2,479.00 $838.92 $495.80
Catheterization.
0082............. Coronary or Non- T............... 87.5137 $5,574.10 ........... $1,114.82
Coronary Atherectomy.
0083............. Coronary or Non- T............... 45.3845 $2,890.72 ........... $578.14
Coronary Angioplasty
and Percutaneous
Valvuloplasty.
0084............. Level I S............... 9.5834 $610.41 ........... $122.08
Electrophysiologic
Procedures.
0085............. Level II T............... 47.2949 $3,012.40 ........... $602.48
Electrophysiologic
Procedures.
0086............. Level III T............... 92.8564 $5,914.40 ........... $1,182.88
Electrophysiologic
Procedures.
0088............. Thrombectomy........... T............... 38.7673 $2,469.24 $655.22 $493.85
0089............. Insertion/Replacement T............... 121.6508 $7,748.43 $1,682.28 $1,549.69
of Permanent Pacemaker
and Electrodes.
0090............. Insertion/Replacement T............... 100.8341 $6,422.53 $1,612.80 $1,284.51
of Pacemaker Pulse
Generator.
0091............. Level II Vascular T............... 42.6114 $2,714.09 ........... $542.82
Ligation.
0092............. Level I Vascular T............... 25.8410 $1,645.92 ........... $329.18
Ligation.
0093............. Vascular Reconstruction/ T............... 30.1294 $1,919.06 ........... $383.81
Fistula Repair without
Device.
0094............. Level I Resuscitation S............... 2.4590 $156.62 $46.29 $31.32
and Cardioversion.
0095............. Cardiac Rehabilitation. S............... 0.5685 $36.21 $13.86 $7.24
0096............. Non-Invasive Vascular S............... 1.4689 $93.56 $37.42 $18.71
Studies.
0097............. Cardiac and Ambulatory X............... 1.0015 $63.79 $23.79 $12.76
Blood Pressure
Monitoring.
0099............. Electrocardiograms..... S............... 0.3892 $24.79 ........... $4.96
0100............. Cardiac Stress Tests... X............... 2.5547 $162.72 $41.44 $32.54
0101............. Tilt Table Evaluation.. S............... 4.1973 $267.34 $100.24 $53.47
0103............. Miscellaneous Vascular T............... 14.6576 $933.60 ........... $186.72
Procedures.
0104............. Transcatheter Placement T............... 89.0159 $5,669.78 ........... $1,133.96
of Intracoronary
Stents.
0105............. Repair/Revision/Removal T............... 23.9802 $1,527.39 ........... $305.48
of Pacemakers, AICDs,
or Vascular Devices.
0106............. Insertion/Replacement T............... 69.5217 $4,428.12 ........... $885.62
of Pacemaker Leads and/
or Electrodes.
0107............. Insertion of T............... 333.8096 $21,261.67 ........... $4,252.33
Cardioverter-
Defibrillator.
0108............. Insertion/Replacement/ T............... 404.8543 $25,786.79 ........... $5,157.36
Repair of Cardioverter-
Defibrillator Leads.
0109............. Removal/Repair of T............... 5.6614 $360.60 ........... $72.12
Implanted Devices.
0110............. Transfusion............ S............... 3.3967 $216.35 ........... $43.27
0111............. Blood Product Exchange. S............... 11.5058 $732.85 $198.40 $146.57
0112............. Apheresis and Stem Cell S............... 30.6035 $1,949.26 $433.29 $389.85
Procedures.
0113............. Excision Lymphatic T............... 22.9584 $1,462.31 ........... $292.46
System.
0114............. Thyroid/Lymphadenectomy T............... 44.3240 $2,823.17 ........... $564.63
Procedures.
0115............. Cannula/Access Device T............... 29.6965 $1,891.49 ........... $378.30
Procedures.
[[Page 66936]]
0121............. Level I Tube changes T............... 3.2383 $206.26 $43.80 $41.25
and Repositioning.
0125............. Refilling of Infusion T............... 2.3544 $149.96 ........... $29.99
Pump.
0126............. Level I Urinary and T............... 1.0356 $65.96 $16.21 $13.19
Anal Procedures.
0127............. Level IV Stereotactic S............... 126.4653 $8,055.08 ........... $1,611.02
Radiosurgery, MRgFUS,
and MEG.
0128............. Echocardiogram with S............... 8.4896 $540.74 $216.29 $108.15
Contrast.
0130............. Level I Laparoscopy.... T............... 34.3958 $2,190.81 $659.53 $438.16
0131............. Level II Laparoscopy... T............... 45.5317 $2,900.10 $1,001.89 $580.02
0132............. Level III Laparoscopy.. T............... 69.6652 $4,437.26 $1,239.22 $887.45
0133............. Level I Skin Repair.... T............... 1.2792 $81.48 $25.67 $16.30
0134............. Level II Skin Repair... T............... 2.1051 $134.08 $42.24 $26.82
0135............. Level III Skin Repair.. T............... 4.5263 $288.30 ........... $57.66
0136............. Level IV Skin Repair... T............... 15.0458 $958.33 ........... $191.67
0137............. Level V Skin Repair.... T............... 20.2069 $1,287.06 ........... $257.41
0140............. Esophageal Dilation T............... 5.8431 $372.17 $91.40 $74.43
without Endoscopy.
0141............. Level I Upper GI T............... 8.5030 $541.59 $143.38 $108.32
Procedures.
0142............. Small Intestine T............... 9.5292 $606.95 $152.78 $121.39
Endoscopy.
0143............. Lower GI Endoscopy..... T............... 8.8486 $563.60 $186.06 $112.72
0146............. Level I Sigmoidoscopy T............... 5.0972 $324.66 ........... $64.93
and Anoscopy.
0147............. Level II Sigmoidoscopy T............... 8.7031 $554.34 ........... $110.87
and Anoscopy.
0148............. Level I Anal/Rectal T............... 4.7935 $305.32 ........... $61.06
Procedures.
0149............. Level III Anal/Rectal T............... 22.7451 $1,448.73 $293.06 $289.75
Procedures.
0150............. Level IV Anal/Rectal T............... 30.1606 $1,921.05 $437.12 $384.21
Procedures.
0151............. Endoscopic Retrograde T............... 20.9510 $1,334.45 ........... $266.89
Cholangio-
Pancreatography (ERCP).
0152............. Level I Percutaneous T............... 28.6884 $1,827.28 ........... $365.46
Abdominal and Biliary
Procedures.
0153............. Peritoneal and T............... 25.6947 $1,636.60 $397.95 $327.32
Abdominal Procedures.
0154............. Hernia/Hydrocele T............... 30.6788 $1,954.06 $464.85 $390.81
Procedures.
0155............. Level II Anal/Rectal T............... 10.9132 $695.11 ........... $139.02
Procedures.
0156............. Level III Urinary and T............... 3.0469 $194.07 ........... $38.81
Anal Procedures.
0157............. Colorectal Cancer S............... 2.0651 $131.53 ........... $26.31
Screening: Barium
Enema.
0158............. Colorectal Cancer T............... 7.8504 $500.02 ........... $125.01
Screening: Colonoscopy.
0159............. Colorectal Cancer S............... 4.7010 $299.43 ........... $74.86
Screening: Flexible
Sigmoidoscopy.
0160............. Level I T............... 5.9735 $380.48 ........... $76.10
Cystourethroscopy and
other Genitourinary
Procedures.
0161............. Level II T............... 17.9420 $1,142.80 $241.15 $228.56
Cystourethroscopy and
other Genitourinary
Procedures.
0162............. Level III T............... 24.7749 $1,578.01 ........... $315.60
Cystourethroscopy and
other Genitourinary
Procedures.
0163............. Level IV T............... 36.0774 $2,297.91 ........... $459.58
Cystourethroscopy and
other Genitourinary
Procedures.
0164............. Level II Urinary and T............... 2.0077 $127.88 ........... $25.58
Anal Procedures.
0165............. Level IV Urinary and T............... 19.3414 $1,231.93 ........... $246.39
Anal Procedures.
0166............. Level I Urethral T............... 19.1505 $1,219.77 ........... $243.95
Procedures.
0168............. Level II Urethral T............... 29.7864 $1,897.21 $388.16 $379.44
Procedures.
0169............. Lithotripsy............ T............... 41.5299 $2,645.21 $997.74 $529.04
0170............. Dialysis............... S............... 6.5383 $416.45 ........... $83.29
0181............. Level II Male Genital T............... 33.9306 $2,161.18 $621.82 $432.24
Procedures.
0183............. Level I Male Genital T............... 22.3251 $1,421.97 ........... $284.39
Procedures.
0184............. Prostate Biopsy........ T............... 11.0338 $702.79 ........... $140.56
0188............. Level II Female T............... 1.3520 $86.11 ........... $17.22
Reproductive Proc.
0189............. Level III Female T............... 2.7584 $175.69 ........... $35.14
Reproductive Proc.
0190............. Level I Hysteroscopy... T............... 21.6576 $1,379.46 $424.28 $275.89
0191............. Level I Female T............... 0.1309 $8.34 $2.36 $1.67
Reproductive Proc.
0192............. Level IV Female T............... 6.0783 $387.15 ........... $77.43
Reproductive Proc.
0193............. Level V Female T............... 19.0203 $1,211.48 ........... $242.30
Reproductive Proc.
0195............. Level VI Female T............... 32.4237 $2,065.20 $483.80 $413.04
Reproductive
Procedures.
0202............. Level VII Female T............... 42.7099 $2,720.36 $981.50 $544.07
Reproductive
Procedures.
0203............. Level IV Nerve T............... 14.4879 $922.79 $240.33 $184.56
Injections.
0204............. Level I Nerve T............... 2.3213 $147.85 $40.13 $29.57
Injections.
0206............. Level II Nerve T............... 4.0964 $260.92 $56.01 $52.18
Injections.
0207............. Level III Nerve T............... 7.0546 $449.34 ........... $89.87
Injections.
0208............. Laminotomies and T............... 46.7724 $2,979.12 ........... $595.82
Laminectomies.
0209............. Level II Extended EEG S............... 11.2822 $718.61 $268.73 $143.72
and Sleep Studies.
0212............. Nervous System T............... 8.5263 $543.07 ........... $108.61
Injections.
0213............. Level I Extended EEG S............... 2.2980 $146.37 $53.58 $29.27
and Sleep Studies.
0215............. Level I Nerve and S............... 0.5804 $36.97 ........... $7.39
Muscle Tests.
0216............. Level III Nerve and S............... 2.6846 $170.99 ........... $34.20
Muscle Tests.
0218............. Level II Nerve and S............... 1.1550 $73.57 ........... $14.71
Muscle Tests.
0220............. Level I Nerve T............... 18.0518 $1,149.79 ........... $229.96
Procedures.
0221............. Level II Nerve T............... 33.2707 $2,119.14 $463.62 $423.83
Procedures.
0222............. Level II Implantation S............... 240.7990 $15,337.45 ........... $3,067.49
of Neurostimulator.
0224............. Implantation of T............... 36.2768 $2,310.61 ........... $462.12
Catheter/Reservoir/
Shunt.
0225............. Implantation of S............... 220.7642 $14,061.35 ........... $2,812.27
Neurostimulator
Electrodes, Cranial
Nerve.
0227............. Implantation of Drug T............... 183.8928 $11,712.87 ........... $2,342.57
Infusion Device.
0229............. Transcatherter T............... 88.5367 $5,639.26 ........... $1,127.85
Placement of
Intravascular Shunts.
0230............. Level I Eye Tests & S............... 0.5903 $37.60 ........... $7.52
Treatments.
0231............. Level III Eye Tests & S............... 2.1790 $138.79 ........... $27.76
Treatments.
0232............. Level I Anterior T............... 5.1169 $325.92 $81.65 $65.18
Segment Eye Procedures.
0233............. Level II Anterior T............... 16.1710 $1,030.00 $266.33 $206.00
Segment Eye Procedures.
0234............. Level III Anterior T............... 23.1758 $1,476.16 $511.31 $295.23
Segment Eye Procedures.
0235............. Level I Posterior T............... 4.1331 $263.25 $58.93 $52.65
Segment Eye Procedures.
0236............. Level II Posterior T............... 18.2350 $1,161.46 ........... $232.29
Segment Eye Procedures.
0237............. Level III Posterior T............... 27.8450 $1,773.56 ........... $354.71
Segment Eye Procedures.
0238............. Level I Repair and T............... 2.9022 $184.85 ........... $36.97
Plastic Eye Procedures.
0239............. Level II Repair and T............... 7.2847 $463.99 ........... $92.80
Plastic Eye Procedures.
[[Page 66937]]
0240............. Level III Repair and T............... 18.7307 $1,193.03 $309.52 $238.61
Plastic Eye Procedures.
0241............. Level IV Repair and T............... 24.3077 $1,548.25 $383.45 $309.65
Plastic Eye Procedures.
0242............. Level V Repair and T............... 37.7243 $2,402.81 $597.36 $480.56
Plastic Eye Procedures.
0243............. Strabismus/Muscle T............... 24.1291 $1,536.88 $430.35 $307.38
Procedures.
0244............. Corneal and Amniotic T............... 37.4896 $2,387.86 $803.26 $477.57
Membrane Transplant.
0245............. Level I Cataract T............... 14.9171 $950.13 $217.05 $190.03
Procedures without IOL
Insert.
0246............. Cataract Procedures T............... 23.8649 $1,520.05 $495.96 $304.01
with IOL Insert.
0247............. Laser Eye Procedures... T............... 5.2001 $331.22 $104.31 $66.24
0249............. Level II Cataract T............... 28.7035 $1,828.24 $524.67 $365.65
Procedures without IOL
Insert.
0250............. Nasal Cauterization/ T............... 1.1251 $71.66 $25.10 $14.33
Packing.
0251............. Level I ENT Procedures. T............... 2.5002 $159.25 ........... $31.85
0252............. Level II ENT Procedures T............... 7.4474 $474.35 $109.16 $94.87
0253............. Level III ENT T............... 16.3288 $1,040.05 $282.29 $208.01
Procedures.
0254............. Level IV ENT Procedures T............... 23.9765 $1,527.16 $321.35 $305.43
0256............. Level V ENT Procedures. T............... 39.8776 $2,539.96 ........... $507.99
0258............. Tonsil and Adenoid T............... 22.2557 $1,417.55 $437.25 $283.51
Procedures.
0259............. Level VI ENT Procedures T............... 393.2242 $25,046.02 $8,543.66 $5,009.20
0260............. Level I Plain Film X............... 0.6954 $44.29 ........... $8.86
Except Teeth.
0261............. Level II Plain Film X............... 1.1570 $73.69 ........... $14.74
Except Teeth Including
Bone Density
Measurement.
0262............. Plain Film of Teeth.... X............... 0.5749 $36.62 ........... $7.32
0263............. Level I Miscellaneous X............... 2.6838 $170.94 ........... $34.19
Radiology Procedures.
0265............. Level I Diagnostic and S............... 0.9570 $60.96 $22.35 $12.19
Screening Ultrasound.
0266............. Level II Diagnostic and S............... 1.5094 $96.14 $37.80 $19.23
Screening Ultrasound.
0267............. Level III Diagnostic S............... 2.3792 $151.54 $60.50 $30.31
and Screening
Ultrasound.
0269............. Level II Echocardiogram S............... 6.3751 $406.06 ........... $81.21
Without Contrast
Except Transesophageal.
0270............. Transesophageal S............... 8.2165 $523.34 $141.32 $104.67
Echocardiogram Without
Contrast.
0272............. Fluoroscopy............ X............... 1.3271 $84.53 $31.64 $16.91
0274............. Myelography............ S............... 7.5589 $481.46 ........... $96.29
0275............. Arthrography........... S............... 4.0031 $254.97 $69.09 $50.99
0276............. Level I Digestive S............... 1.3834 $88.11 $34.97 $17.62
Radiology.
0277............. Level II Digestive S............... 2.2222 $141.54 $54.52 $28.31
Radiology.
0278............. Diagnostic Urography... S............... 2.6121 $166.38 $59.40 $33.28
0279............. Level II Angiography S............... 28.8788 $1,839.41 ........... $367.88
and Venography.
0280............. Level III Angiography S............... 44.7114 $2,847.85 ........... $569.57
and Venography.
0282............. Miscellaneous Computed S............... 1.5839 $100.88 $37.81 $20.18
Axial Tomography.
0283............. Computed Tomography S............... 4.3564 $277.48 $100.37 $55.50
with Contrast.
0284............. Magnetic Resonance S............... 6.2350 $397.13 $148.40 $79.43
Imaging and Magnetic
Resonance Angiography
with Contrast.
0288............. Bone Density:Axial S............... 1.1384 $72.51 $28.90 $14.50
Skeleton.
0293............. Level V Anterior T............... 84.8039 $5,401.50 $1,128.29 $1,080.30
Segment Eye Procedures.
0299............. Hyperthermia and S............... 5.7996 $369.40 ........... $73.88
Radiation Treatment
Procedures.
0300............. Level I Radiation S............... 1.4229 $90.63 ........... $18.13
Therapy.
0301............. Level II Radiation S............... 2.2167 $141.19 ........... $28.24
Therapy.
0303............. Treatment Device X............... 2.8878 $183.94 $66.95 $36.79
Construction.
0304............. Level I Therapeutic X............... 1.5576 $99.21 $38.68 $19.84
Radiation Treatment
Preparation.
0305............. Level II Therapeutic X............... 3.9276 $250.16 $91.38 $50.03
Radiation Treatment
Preparation.
0307............. Myocardial Positron S............... 21.9955 $1,400.98 $292.49 $280.20
Emission Tomography
(PET) imaging.
0308............. Non-Myocardial Positron S............... 16.6001 $1,057.33 ........... $211.47
Emission Tomography
(PET) imaging.
0310............. Level III Therapeutic X............... 13.5621 $863.82 $325.27 $172.76
Radiation Treatment
Preparation.
0312............. Radioelement S............... 8.5140 $542.29 ........... $108.46
Applications.
0313............. Brachytherapy.......... S............... 11.6779 $743.81 ........... $148.76
0315............. Level III Implantation S............... 270.0190 $17,198.59 ........... $3,439.72
of Neurostimulator.
0317............. Level II Miscellaneous X............... 5.3623 $341.55 $77.89 $68.31
Radiology Procedures.
0320............. Electroconvulsive S............... 5.7299 $364.96 $80.06 $72.99
Therapy.
0322............. Brief Individual S............... 1.1729 $74.71 ........... $14.94
Psychotherapy.
0323............. Extended Individual S............... 1.6044 $102.19 ........... $20.44
Psychotherapy.
0324............. Family Psychotherapy... S............... 2.3616 $150.42 ........... $30.08
0325............. Group Psychotherapy.... S............... 0.9913 $63.14 $13.81 $12.63
0330............. Dental Procedures...... S............... 9.1677 $583.93 ........... $116.79
0332............. Computed Tomography S............... 3.0109 $191.78 $75.24 $38.36
without Contrast.
0333............. Computed Tomography S............... 5.1125 $325.64 $119.01 $65.13
without Contrast
followed by Contrast).
0335............. Magnetic Resonance S............... 4.8830 $311.02 $111.92 $62.20
Imaging, Miscellaneous.
0336............. Magnetic Resonance S............... 5.3933 $343.52 $137.40 $68.70
Imaging and Magnetic
Resonance Angiography
without Contrast.
0337............. Magnetic Resonance S............... 8.2463 $525.24 $199.53 $105.05
Imaging and Magnetic
Resonance Angiography
without Contrast
followed by Contrast.
0340............. Minor Ancillary X............... 0.6310 $40.19 ........... $8.04
Procedures.
0341............. Skin Tests............. X............... 0.0844 $5.38 $2.14 $1.08
0342............. Level I Pathology...... X............... 0.0969 $6.17 $2.02 $1.23
0343............. Level III Pathology.... X............... 0.5142 $32.75 $10.84 $6.55
0344............. Level IV Pathology..... X............... 0.8167 $52.02 $15.66 $10.40
0345............. Level I Transfusion X............... 0.2140 $13.63 $2.87 $2.73
Laboratory Procedures.
0346............. Level II Transfusion X............... 0.3346 $21.31 $4.37 $4.26
Laboratory Procedures.
0347............. Level III Transfusion X............... 0.7739 $49.29 $11.28 $9.86
Laboratory Procedures.
0350............. Administration of flu S............... 0.3945 $25.13 ........... $0.00
and PPV vaccine.
0360............. Level I Alimentary X............... 1.5330 $97.64 $33.88 $19.53
Tests.
0361............. Level II Alimentary X............... 3.9276 $250.16 $83.23 $50.03
Tests.
0363............. Level I X............... 0.8067 $51.38 $17.10 $10.28
Otorhinolaryngologic
Function Tests.
0364............. Level I Audiometry..... X............... 0.4490 $28.60 $7.06 $5.72
0365............. Level II Audiometry.... X............... 1.2549 $79.93 $18.52 $15.99
[[Page 66938]]
0366............. Level III Audiometry... X............... 1.7624 $112.25 $25.79 $22.45
0367............. Level I Pulmonary Test. X............... 0.5677 $36.16 $13.76 $7.23
0368............. Level II Pulmonary X............... 0.9253 $58.94 $22.77 $11.79
Tests.
0369............. Level III Pulmonary X............... 2.7550 $175.48 $44.18 $35.10
Tests.
0370............. Allergy Tests.......... X............... 1.0430 $66.43 ........... $13.29
0373............. Level I X............... 1.2448 $79.29 ........... $15.86
Neuropsychological
Testing.
0375............. Ancillary Outpatient S............... 78.5966 $5,006.13 ........... $1,001.23
Services When Patient
Expires.
0377............. Level II Cardiac S............... 11.8512 $754.85 $158.84 $150.97
Imaging.
0378............. Level II Pulmonary S............... 4.9509 $315.34 $125.33 $63.07
Imaging.
0379............. Injection adenosine 6 K............... ........... $25.10 ........... $5.02
MG.
0381............. Single Allergy Tests... X............... 0.2773 $17.66 ........... $3.53
0382............. Level II X............... 2.6169 $166.68 ........... $33.34
Neuropsychological
Testing.
0383............. Cardiac Computed S............... 4.7005 $299.39 $117.06 $59.88
Tomographic Imaging.
0384............. GI Procedures with T............... 24.9814 $1,591.17 ........... $318.23
Stents.
0385............. Level I Prosthetic S............... 83.6366 $5,327.15 ........... $1,065.43
Urological Procedures.
0386............. Level II Prosthetic S............... 144.1246 $9,179.87 ........... $1,835.97
Urological Procedures.
0387............. Level II Hysteroscopy.. T............... 34.2048 $2,178.64 $655.55 $435.73
0388............. Discography............ S............... 20.1823 $1,285.49 $289.72 $257.10
0389............. Level I Non-imaging S............... 1.8190 $115.86 $33.81 $23.17
Nuclear Medicine.
0390............. Level I Endocrine S............... 2.0471 $130.39 $52.15 $26.08
Imaging.
0391............. Level II Endocrine S............... 3.4513 $219.83 $66.18 $43.97
Imaging.
0392............. Level II Non-imaging S............... 2.9022 $184.85 $49.31 $36.97
Nuclear Medicine.
0393............. Hematologic Processing S............... 5.6921 $362.55 $82.04 $72.51
& Studies.
0394............. Hepatobiliary Imaging.. S............... 4.4603 $284.09 $102.61 $56.82
0395............. GI Tract Imaging....... S............... 3.7911 $241.47 $89.73 $48.29
0396............. Bone Imaging........... S............... 3.8039 $242.29 $95.02 $48.46
0397............. Vascular Imaging....... S............... 3.1433 $200.21 $49.58 $40.04
0398............. Level I Cardiac Imaging S............... 4.8620 $309.68 $100.06 $61.94
0400............. Hematopoietic Imaging.. S............... 3.9293 $250.27 $93.22 $50.05
0401............. Level I Pulmonary S............... 3.3954 $216.27 $78.19 $43.25
Imaging.
0402............. Level II Nervous System S............... 8.8235 $562.00 $114.12 $112.40
Imaging.
0403............. Level I Nervous System S............... 3.2295 $205.70 $79.87 $41.14
Imaging.
0404............. Renal and Genitourinary S............... 5.0824 $323.72 $84.11 $64.74
Studies.
0406............. Level I Tumor/Infection S............... 5.0681 $322.81 $98.18 $64.56
Imaging.
0407............. Level I Radionuclide S............... 3.3020 $210.32 $78.13 $42.06
Therapy.
0408............. Level III Tumor/ S............... 15.4033 $981.10 ........... $196.22
Infection Imaging.
0409............. Red Blood Cell Tests... X............... 0.1190 $7.58 $2.20 $1.52
0412............. IMRT Treatment Delivery S............... 5.4582 $347.65 ........... $69.53
0413............. Level II Radionuclide S............... 5.2741 $335.93 ........... $67.19
Therapy.
0414............. Level II Tumor/ S............... 8.4176 $536.15 $214.44 $107.23
Infection Imaging.
0415............. Level II Endoscopy T............... 24.0654 $1,532.82 $459.92 $306.56
Lower Airway.
0418............. Insertion of Left T............... 259.7486 $16,544.43 . $3,308.89
Ventricular Pacing
Elect.
0422............. Level II Upper GI T............... 25.3233 $1,612.94 $448.81 $322.59
Procedures.
0423............. Level II Percutaneous T............... 42.9980 $2,738.71 ........... $547.74
Abdominal and Biliary
Procedures.
0425............. Level II Arthroplasty T............... 122.2057 $7,783.77 ........... $1,556.75
with Prosthesis.
0426............. Level II Strapping and S............... 2.2910 $145.92 ........... $29.18
Cast Application.
0427............. Level II Tube Changes T............... 15.3545 $977.99 ........... $195.60
and Repositioning.
0428............. Level III Sigmoidoscopy T............... 21.4632 $1,367.08 ........... $273.42
and Anoscopy.
0429............. Level V T............... 45.2042 $2,879.24 ........... $575.85
Cystourethroscopy and
other Genitourinary
Procedures.
0430............. Drug Preadministration- S............... 0.5921 $37.71 ........... $7.54
Related Services.
0432............. Health and Behavior S............... 0.3128 $19.92 ........... $3.98
Services.
0433............. Level II Pathology..... X............... 0.2397 $15.27 $5.17 $3.05
0434............. Cardiac Defect Repair.. T............... 132.4129 $8,433.91 ........... $1,686.78
0436............. Level I Drug S............... 0.2545 $16.21 ........... $3.24
Administration.
0437............. Level II Drug S............... 0.3945 $25.13 ........... $5.03
Administration.
0438............. Level III Drug S............... 0.8041 $51.22 ........... $10.24
Administration.
0439............. Level IV Drug S............... 1.6544 $105.38 ........... $21.08
Administration.
0440............. Level V Drug S............... 1.7998 $114.64 ........... $22.93
Administration.
0441............. Level VI Drug S............... 2.3446 $149.34 ........... $29.87
Administration.
0442............. Dosimetric Drug S............... 27.4298 $1,747.11 ........... $349.42
Administration.
0604............. Level 1 Hospital Clinic V............... 0.8388 $53.43 ........... $10.69
Visits.
0605............. Level 2 Hospital Clinic V............... 0.9964 $63.46 ........... $12.69
Visits.
0606............. Level 3 Hospital Clinic V............... 1.3226 $84.24 ........... $16.85
Visits.
0607............. Level 4 Hospital Clinic V............... 1.6604 $105.76 ........... $21.15
Visits.
0608............. Level 5 Hospital Clinic V............... 2.1740 $138.47 ........... $27.69
Visits.
0609............. Level 1 Emergency V............... 0.7970 $50.76 $12.70 $10.15
Visits.
0613............. Level 2 Emergency V............... 1.3137 $83.67 $21.06 $16.73
Visits.
0614............. Level 3 Emergency V............... 2.0750 $132.17 $34.50 $26.43
Visits.
0615............. Level 4 Emergency V............... 3.3377 $212.59 $48.49 $42.52
Visits.
0616............. Level 5 Emergency V............... 4.9535 $315.51 $72.86 $63.10
Visits.
0617............. Critical Care.......... S............... 7.3166 $466.02 $111.59 $93.20
0618............. Trauma Response with S............... 5.1854 $330.28 $132.11 $66.06
Critical Care.
0621............. Level I Vascular Access T............... 10.9092 $694.85 ........... $138.97
Procedures.
0622............. Level II Vascular T............... 24.1069 $1,535.46 ........... $307.09
Access Procedures.
0623............. Level III Vascular T............... 28.8743 $1,839.12 ........... $367.82
Access Procedures.
0624............. Phlebotomy and Minor X............... 0.5689 $36.24 $12.65 $7.25
Vascular Access Device
Procedures.
0625............. Level IV Vascular T............... 81.7482 $5,206.87 ........... $1,041.37
Access Procedures.
0648............. Level IV Breast Surgery T............... 56.5774 $3,603.64 ........... $720.73
0651............. Complex Interstitial S............... 18.1228 $1,154.31 ........... $230.86
Radiation Source
Application.
0652............. Insertion of T............... 30.7096 $1,956.02 ........... $391.20
Intraperitoneal and
Pleural Catheters.
[[Page 66939]]
0653............. Vascular Reconstruction/ T............... 40.4667 $2,577.49 ........... $515.50
Fistula Repair with
Device.
0654............. Insertion/Replacement T............... 109.2851 $6,960.81 ........... $1,392.16
of a permanent dual
chamber pacemaker.
0655............. Insertion/Replacement/ T............... 140.0317 $8,919.18 ........... $1,783.84
Conversion of a
permanent dual chamber
pacemaker.
0656............. Transcatheter Placement T............... 118.4265 $7,543.06 ........... $1,508.61
of Intracoronary Drug-
Eluting Stents.
0659............. Hyperbaric Oxygen...... S............... 1.5579 $99.23 ........... $19.85
0660............. Level II X............... 1.4312 $91.16 $28.06 $18.23
Otorhinolaryngologic
Function Tests.
0661............. Level V Pathology...... X............... 2.6949 $171.65 $62.09 $34.33
0662............. CT Angiography......... S............... 5.1641 $328.92 $118.88 $65.78
0663............. Level I Electronic S............... 1.5313 $97.53 ........... $19.51
Analysis of Devices.
0664............. Level I Proton Beam S............... 12.8205 $816.59 ........... $163.32
Radiation Therapy.
0665............. Bone S............... 0.5087 $32.40 $12.95 $6.48
Density:AppendicularSk
eleton.
0667............. Level II Proton Beam S............... 15.3404 $977.09 ........... $195.42
Radiation Therapy.
0668............. Level I Angiography and S............... 9.3506 $595.58 ........... $119.12
Venography.
0672............. Level IV Posterior T............... 37.2078 $2,369.91 ........... $473.98
Segment Eye Procedures.
0673............. Level IV Anterior T............... 39.7101 $2,529.30 $649.56 $505.86
Segment Eye Procedures.
0674............. Prostate Cryoablation.. T............... 122.7133 $7,816.10 ........... $1,563.22
0676............. Thrombolysis and T............... 2.4824 $158.11 ........... $31.62
Thrombectomy.
0678............. External T............... 1.7187 $109.47 ........... $21.89
Counterpulsation.
0679............. Level II Resuscitation S............... 5.4502 $347.15 $95.30 $69.43
and Cardioversion.
0680............. Insertion of Patient S............... 70.6073 $4,497.26 ........... $899.45
Activated Event
Recorders.
0681............. Knee Arthroplasty...... T............... 274.6715 $17,494.93 ........... $3,498.99
0682............. Level V Debridement & T............... 6.8816 $438.32 $158.65 $87.66
Destruction.
0683............. Level II S............... 2.6045 $165.89 ........... $33.18
Photochemotherapy.
0685............. Level III Needle Biopsy/ T............... 9.3354 $594.61 ........... $118.92
Aspiration Except Bone
Marrow.
0687............. Revision/Removal of T............... 22.4734 $1,431.42 $438.47 $286.28
Neurostimulator
Electrodes.
0688............. Revision/Removal of T............... 34.4166 $2,192.13 $874.57 $438.43
Neurostimulator Pulse
Generator Receiver.
0689............. Electronic Analysis of S............... 0.5946 $37.87 ........... $7.57
Cardioverter-
defibrillators.
0690............. Electronic Analysis of S............... 0.3504 $22.32 $8.67 $4.46
Pacemakers and other
Cardiac Devices.
0691............. Level III Electronic S............... 2.3269 $148.21 $50.49 $29.64
Analysis of Devices.
0692............. Level II Electronic S............... 1.8376 $117.04 $29.72 $23.41
Analysis of Devices.
0694............. Mohs Surgery........... T............... 3.6321 $231.34 $91.69 $46.27
0697............. Level I Echocardiogram S............... 3.3401 $212.74 ........... $42.55
Without Contrast
Except Transesophageal.
0698............. Level II Eye Tests & S............... 0.8696 $55.39 ........... $11.08
Treatments.
0699............. Level IV Eye Tests & T............... 13.7453 $875.49 ........... $175.10
Treatments.
0701............. Sr89 strontium......... K............... 9.6094 $612.06 ........... $122.41
0702............. Sm 153 lexidronm....... K............... 21.3689 $1,361.07 ........... $272.21
0726............. Dexrazoxane HCl K............... ........... $162.11 ........... $32.42
injection.
0728............. Filgrastim 300 mcg K............... ........... $193.79 ........... $38.76
injection.
0730............. Pamidronate disodium... K............... ........... $28.31 ........... $5.66
0731............. Sargramostim injection. K............... ........... $24.86 ........... $4.97
0732............. Mesna injection........ K............... ........... $7.97 ........... $1.59
0735............. Ampho b cholesteryl K............... ........... $11.89 ........... $2.38
sulfate.
0736............. Amphotericin b liposome K............... ........... $16.21 ........... $3.24
inj.
0738............. Rasburicase............ K............... ........... $144.43 ........... $28.89
0747............. Chlorothiazide sodium K............... ........... $141.07 ........... $28.21
inj.
0748............. Bleomycin sulfate K............... ........... $42.93 ........... $8.59
injection.
0750............. Dolasetron mesylate.... K............... ........... $4.66 ........... $0.93
0751............. Mechlorethamine hcl inj K............... ........... $143.08 ........... $28.62
0752............. Dactinomycin K............... ........... $488.78 ........... $97.76
actinomycin d.
0759............. Naltrexone, depot form. K............... ........... $1.87 ........... $0.37
0760............. Anadulafungin injection G............... ........... $1.91 ........... $0.38
0763............. Dolasetron mesylate K............... ........... $43.77 ........... $8.75
oral.
0764............. Granisetron HCl K............... ........... $5.74 ........... $1.15
injection.
0765............. Granisetron HCl 1 mg K............... ........... $49.96 ........... $9.99
oral.
0767............. Enfuvirtide injection.. K............... ........... $0.40 ........... $0.08
0768............. Ondansetron hcl K............... ........... $0.26 ........... $0.06
injection.
0769............. Ondansetron HCl 8mg K............... ........... $18.37 ........... $3.67
oral.
0800............. Leuprolide acetate..... K............... ........... $452.58 ........... $90.52
0802............. Etoposide oral......... K............... ........... $29.46 ........... $5.89
0804............. Vivaglobin, inj........ K............... ........... $7.01 ........... $1.40
0805............. Mecasermin injection... K............... ........... $15.62 ........... $3.12
0806............. Hyaluronidase G............... ........... $0.40 ........... $0.08
recombinant.
0807............. Aldesleukin/single use K............... ........... $788.84 ........... $157.77
vial.
0808............. Nabilone oral.......... K............... ........... $16.80 ........... $3.36
0809............. Bcg live intravesical K............... ........... $113.75 ........... $22.75
vac.
0810............. Goserelin acetate K............... ........... $192.29 ........... $38.46
implant.
0811............. Carboplatin injection.. K............... ........... $7.44 ........... $1.49
0812............. Carmus bischl nitro inj K............... ........... $152.24 ........... $30.45
0814............. Asparaginase injection. K............... ........... $54.26 ........... $10.85
0820............. Daunorubicin........... K............... ........... $19.33 ........... $3.87
0821............. Daunorubicin citrate K............... ........... $55.23 ........... $11.05
liposom.
0823............. Docetaxel.............. K............... ........... $310.85 ........... $62.17
0825............. Nelarabine injection... G............... ........... $86.84 ........... $17.37
0827............. Floxuridine injection.. K............... ........... $54.63 ........... $10.93
0828............. Gemcitabine HCl........ K............... ........... $127.31 ........... $25.46
0830............. Irinotecan injection... K............... ........... $124.61 ........... $24.92
0831............. Ifosfomide injection... K............... ........... $38.13 ........... $7.63
0832............. Idarubicin hcl K............... ........... $302.42 ........... $60.48
injection.
0834............. Interferon alfa-2a inj. K............... ........... $41.37 ........... $8.27
[[Page 66940]]
0835............. Inj cosyntropin........ K............... ........... $64.01 ........... $12.80
0836............. Interferon alfa-2b inj. K............... ........... $13.92 ........... $2.78
0838............. Interferon gamma 1-b K............... ........... $306.66 ........... $61.33
inj.
0840............. Inj melphalan hydrochl. K............... ........... $1,548.88 ........... $309.78
0842............. Fludarabine phosphate K............... ........... $226.67 ........... $45.33
inj.
0843............. Pegaspargase/singl dose K............... ........... $2,080.19 ........... $416.04
vial.
0844............. Pentostatin injection.. K............... ........... $2,051.68 ........... $410.34
0849............. Rituximab cancer K............... ........... $504.40 ........... $100.88
treatment.
0850............. Streptozocin injection. K............... ........... $146.93 ........... $29.39
0851............. Thiotepa injection..... K............... ........... $41.12 ........... $8.22
0852............. Topotecan.............. K............... ........... $859.62 ........... $171.92
0855............. Vinorelbine tartrate... K............... ........... $21.41 ........... $4.28
0856............. Porfimer sodium........ K............... ........... $2,532.53 ........... $506.51
0858............. Inj cladribine......... K............... ........... $32.04 ........... $6.41
0861............. Leuprolide acetate K............... ........... $7.98 ........... $1.60
injeciton.
0862............. Mitomycin 5 MG inj..... K............... ........... $14.39 ........... $2.88
0863............. Paclitaxel injection... K............... ........... $14.57 ........... $2.91
0864............. Mitoxantrone hydrochl.. K............... ........... $107.96 ........... $21.59
0865............. Interferon alfa-n3 inj. K............... ........... $9.03 ........... $1.81
0868............. Oral aprepitant........ K............... ........... $4.99 ........... $1.00
0873............. Hyalgan/supartz inj per K............... ........... $101.81 ........... $20.36
dose.
0874............. Synvisc inj per dose... K............... ........... $178.11 ........... $35.62
0875............. Euflexxa inj per dose.. K............... ........... $110.95 ........... $22.19
0877............. Orthovisc inj per dose. K............... ........... $174.50 ........... $34.90
0878............. Gallium nitrate K............... ........... $1.61 ........... $0.32
injection.
0880............. Pentastarch 10% K............... ........... $21.98 ........... $4.40
solution.
0882............. Melphalan oral......... K............... ........... $4.14 ........... $0.83
0883............. Fondaparinux sodium.... K............... ........... $5.92 ........... $1.18
0884............. Rho d immune globulin K............... ........... $80.79 ........... $16.16
inj.
0887............. Azathioprine parenteral K............... ........... $47.88 ........... $9.58
0888............. Cyclosporine oral...... K............... ........... $3.52 ........... $0.70
0890............. Lymphocyte immune K............... ........... $336.10 ........... $67.22
globulin.
0891............. Tacrolimus oral........ K............... ........... $3.69 ........... $0.74
0898............. Gamma globulin 2 CC inj K............... ........... $23.82 ........... $4.76
0899............. Gamma globulin 3 CC inj K............... ........... $35.72 ........... $7.14
0900............. Alglucerase injection.. K............... ........... $38.85 ........... $7.77
0901............. Alpha 1 proteinase K............... ........... $3.28 ........... $0.66
inhibitor.
0902............. Botulinum toxin a per K............... ........... $5.21 ........... $1.04
unit.
0903............. Cytomegalovirus imm IV / K............... ........... $870.53 ........... $174.11
vial.
0904............. Gamma globulin 4 CC inj K............... ........... $47.64 ........... $9.53
0906............. RSV-ivig............... K............... ........... $16.02 ........... $3.20
0910............. Interferon beta-1b / K............... ........... $106.57 ........... $21.31
.25 MG.
0911............. Inj streptokinase / K............... ........... $129.75 ........... $25.95
250000 IU.
0912............. Interferon alfacon-1... K............... ........... $4.62 ........... $0.92
0913............. Ganciclovir long act K............... ........... $4,707.90 ........... $941.58
implant.
0916............. Injection imiglucerase / K............... ........... $3.89 ........... $0.78
unit.
0917............. Adenosine injection.... K............... ........... $67.89 ........... $13.58
0919............. Gamma globulin 5 CC inj K............... ........... $59.54 ........... $11.91
0920............. Gamma globulin 6 CC inj K............... ........... $71.50 ........... $14.30
0921............. Gamma globulin 7 CC inj K............... ........... $83.30 ........... $16.66
0922............. Gamma globulin 8 CC inj K............... ........... $95.27 ........... $19.05
0923............. Gamma globulin 9 CC inj K............... ........... $107.25 ........... $21.45
0924............. Gamma globulin 10 CC K............... ........... $119.09 ........... $23.82
inj.
0925............. Factor viii............ K............... ........... $0.75 ........... $0.15
0927............. Factor viii recombinant K............... ........... $1.07 ........... $0.21
0928............. Factor ix complex...... K............... ........... $0.80 ........... $0.16
0929............. Anti-inhibitor......... K............... ........... $1.42 ........... $0.28
0930............. Antithrombin iii K............... ........... $1.82 ........... $0.36
injection.
0931............. Factor IX non- K............... ........... $0.89 ........... $0.18
recombinant.
0932............. Factor IX recombinant.. K............... ........... $0.99 ........... $0.20
0933............. Gamma globulin > 10 CC K............... ........... $119.09 ........... $23.82
inj.
0934............. Capecitabine, oral..... K............... ........... $14.19 ........... $2.84
0935............. Clonidine hydrochloride K............... ........... $62.78 ........... $12.56
0941............. Mitomycin 20 MG inj.... K............... ........... $57.56 ........... $11.51
0942............. Mitomycin 40 MG inj.... K............... ........... $115.11 ........... $23.02
0943............. Octagam injection...... K............... ........... $33.19 ........... $6.64
0944............. Gammagard liquid K............... ........... $31.06 ........... $6.21
injection.
0945............. Rhophylac injection.... K............... ........... $5.29 ........... $1.06
0946............. HepaGam B IM injection. K............... ........... $63.51 ........... $12.70
0947............. Flebogamma injection... K............... ........... $32.27 ........... $6.45
0948............. Gamunex injection...... K............... ........... $32.06 ........... $6.41
0949............. Frozen plasma, pooled, K............... 1.1598 $73.87 ........... $14.77
sd.
0950............. Whole blood for K............... 4.0011 $254.85 ........... $50.97
transfusion.
0951............. Reclast injection...... G............... ........... $220.81 ........... $44.16
0952............. Cryoprecipitate each K............... 0.6474 $41.24 ........... $8.25
unit.
0954............. RBC leukocytes reduced. K............... 2.9069 $185.15 ........... $37.03
0955............. Plasma, frz between 8- K............... 1.2235 $77.93 ........... $15.59
24hour.
0956............. Plasma protein K............... 1.4739 $93.88 ........... $18.78
fract,5%,50ml.
0957............. Platelets, each unit... K............... 1.0911 $69.50 ........... $13.90
0958............. Plaelet rich plasma K............... 5.7070 $363.50 ........... $72.70
unit.
[[Page 66941]]
0959............. Red blood cells unit... K............... 2.0356 $129.66 ........... $25.93
0960............. Washed red blood cells K............... 4.3494 $277.03 ........... $55.41
unit.
0961............. Albumin (human),5%, K............... 0.3413 $21.74 ........... $4.35
50ml.
0963............. Albumin (human), 5%, K............... 1.0987 $69.98 ........... $14.00
250 ml.
0964............. Albumin (human), 25%, K............... 0.4118 $26.23 ........... $5.25
20 ml.
0965............. Albumin (human), 25%, K............... 1.1362 $72.37 ........... $14.47
50ml.
0966............. Plasmaprotein K............... 3.3792 $215.23 ........... $43.05
fract,5%,250ml.
0967............. Blood split unit....... K............... 2.3409 $149.10 ........... $29.82
0968............. Platelets leukoreduced K............... 2.1971 $139.94 ........... $27.99
irrad.
0969............. RBC leukoreduced K............... 3.7722 $240.27 ........... $48.05
irradiated.
0998............. Inj biperiden lactate/5 K............... ........... $88.15 ........... $17.63
mg.
0999............. Edetate calcium K............... ........... $49.64 ........... $9.93
disodium inj.
1009............. Cryoprecipitatereducedp K............... 1.3139 $83.69 ........... $16.74
lasma.
1010............. Blood, l/r, cmv-neg.... K............... 2.3221 $147.90 ........... $29.58
1011............. Platelets, hla-m, l/r, K............... 10.1413 $645.94 ........... $129.19
unit.
1013............. Platelets leukocytes K............... 1.6879 $107.51 ........... $21.50
reduced.
1015............. Injection glatiramer K............... ........... $52.04 ........... $10.41
acetate.
1016............. Blood, l/r, froz/degly/ K............... 3.4353 $218.81 ........... $43.76
wash.
1017............. Plt, aph/pher, l/r, cmv- K............... 7.6733 $488.74 ........... $97.75
neg.
1018............. Blood, l/r, irradiated. K............... 2.3099 $147.13 ........... $29.43
1019............. Plate pheres leukoredu K............... 9.8923 $630.08 ........... $126.02
irrad.
1020............. Plt, pher, l/r cmv-neg, K............... 10.7787 $686.54 ........... $137.31
irr.
1021............. RBC, frz/deg/wsh, l/r, K............... 5.8716 $373.99 ........... $74.80
irrad.
1022............. RBC, l/r, cmv-neg, K............... 4.1363 $263.46 ........... $52.69
irrad.
1023............. Pralidoxime chloride K............... ........... $35.20 ........... $7.04
inj.
1032............. Aud osseo dev, int/ext H............... ........... ........... ........... .
comp.
1041............. Plicamycin K............... ........... $172.41 ........... $34.48
(mithramycin) inj.
1052............. Injection, voriconazole K............... ........... $4.93 ........... $0.99
1064............. I131 iodide cap, rx.... K............... 0.2393 $15.24 ........... $3.05
1083............. Adalimumab injection... K............... ........... $329.58 ........... $65.92
1084............. Denileukin diftitox.... K............... ........... $1,386.59 ........... $277.32
1086............. Temozolomide........... K............... ........... $7.49 ........... $1.50
1138............. Hepagam B intravenous, K............... ........... $63.51 ........... $12.70
inj.
1139............. Protein C concentrate.. K............... ........... $12.08 ........... $2.42
1140............. Integra matrix tissue.. K............... ........... $33.14 ........... $6.63
1141............. Primatrix tissue....... G............... ........... $67.96 ........... $13.59
1142............. Supprelin LA implant... K............... ........... $14,700.00 ........... $2,940.00
1150............. I131 iodide sol, rx.... K............... 0.1762 $11.22 ........... $2.24
1165............. Aripiprazole injection. K............... ........... $0.28 ........... $0.06
1166............. Cytarabine liposome.... K............... ........... $412.21 ........... $82.44
1167............. Inj, epirubicin hcl.... K............... ........... $19.79 ........... $3.96
1168............. Inj, temsirolimus...... G............... ........... $48.41 ........... $9.68
1169............. Neurawrap nerve G............... ........... $482.56 ........... $96.51
protector,cm.
1178............. Busulfan injection..... K............... ........... $9.17 ........... $1.83
1203............. Verteporfin injection.. K............... ........... $8.99 ........... $1.80
1207............. Octreotide injection, K............... ........... $99.04 ........... $19.81
depot.
1280............. Corticotropin injection K............... ........... $169.77 ........... $33.95
1436............. Etidronate disodium inj K............... ........... $70.73 ........... $14.15
1491............. New Technology--Level S............... ........... $5.00 ........... $1.00
IA ($0-$10).
1492............. New Technology--Level S............... ........... $15.00 ........... $3.00
IB ($10-$20).
1493............. New Technology--Level S............... ........... $25.00 ........... $5.00
IC ($20-$30).
1494............. New Technology--Level S............... ........... $35.00 ........... $7.00
ID ($30-$40).
1495............. New Technology--Level S............... ........... $45.00 ........... $9.00
IE ($40-$50).
1496............. New Technology--Level T............... ........... $5.00 ........... $1.00
IA ($0-$10).
1497............. New Technology--Level T............... ........... $15.00 ........... $3.00
IB($10-$20).
1498............. New Technology--Level T............... ........... $25.00 ........... $5.00
IC ($20-$30).
1499............. New Technology--Level T............... ........... $35.00 ........... $7.00
ID($30-$40).
1500............. New Technology--Level T............... ........... $45.00 ........... $9.00
IE ($40-$50).
1502............. New Technology--Level S............... ........... $75.00 ........... $15.00
II ($50-$100).
1503............. New Technology--Level S............... ........... $150.00 ........... $30.00
III ($100-$200).
1504............. New Technology--Level S............... ........... $250.00 ........... $50.00
IV ($200-$300).
1505............. New Technology--Level V S............... ........... $350.00 ........... $70.00
($300-$400).
1506............. New Technology--Level S............... ........... $450.00 ........... $90.00
VI ($400-$500).
1507............. New Technology--Level S............... ........... $550.00 ........... $110.00
VII ($500-$600).
1508............. New Technology--Level S............... ........... $650.00 ........... $130.00
VIII ($600-$700).
1509............. New Technology--Level S............... ........... $750.00 ........... $150.00
IX ($700-$800).
1510............. New Technology--Level X S............... ........... $850.00 ........... $170.00
($800-$900).
1511............. New Technology--Level S............... ........... $950.00 ........... $190.00
XI ($900-$1000).
1512............. New Technology--Level S............... ........... $1,050.00 ........... $210.00
XII ($1000-$1100).
1513............. New Technology--Level S............... ........... $1,150.00 ........... $230.00
XIII ($1100-$1200).
1514............. New Technology--Level S............... ........... $1,250.00 ........... $250.00
XIV($1200-$1300).
1515............. New Technology--Level S............... ........... $1,350.00 ........... $270.00
XV ($1300-$1400).
1516............. New Technology--Level S............... ........... $1,450.00 ........... $290.00
XVI ($1400-$1500).
1517............. New Technology--Level S............... ........... $1,550.00 ........... $310.00
XVII ($1500-$1600).
1518............. New Technology--Level S............... ........... $1,650.00 ........... $330.00
XVIII ($1600-$1700).
1519............. New Technology--Level S............... ........... $1,750.00 ........... $350.00
IXX ($1700-$1800).
1520............. New Technology--Level S............... ........... $1,850.00 ........... $370.00
XX ($1800-$1900).
1521............. New Technology--Level S............... ........... $1,950.00 ........... $390.00
XXI ($1900-$2000).
1522............. New Technology--Level S............... ........... $2,250.00 ........... $450.00
XXII ($2000-$2500).
1523............. New Technology--Level S............... ........... $2,750.00 ........... $550.00
XXIII ($2500-$3000).
[[Page 66942]]
1524............. New Technology--Level S............... ........... $3,250.00 ........... $650.00
XXIV ($3000-$3500).
1525............. New Technology--Level S............... ........... $3,750.00 ........... $750.00
XXV ($3500-$4000).
1526............. New Technology--Level S............... ........... $4,250.00 ........... $850.00
XXVI ($4000-$4500).
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 S............... ........... $5,750.00 ........... $1,150.00
XXIX ($5500-$6000).
1530............. New Technology--Level S............... ........... $6,250.00 ........... $1,250.00
XXX ($6000-$6500).
1531............. New Technology--Level S............... ........... $6,750.00 ........... $1,350.00
XXXI ($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 S............... ........... $8,750.00 ........... $1,750.00
XXXV ($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 T............... ........... $75.00 ........... $15.00
II ($50-$100).
1540............. New Technology--Level T............... ........... $150.00 ........... $30.00
III ($100-$200).
1541............. New Technology--Level T............... ........... $250.00 ........... $50.00
IV ($200-$300).
1542............. New Technology--Level V T............... ........... $350.00 ........... $70.00
($300-$400).
1543............. New Technology--Level T............... ........... $450.00 ........... $90.00
VI ($400-$500).
1544............. New Technology--Level T............... ........... $550.00 ........... $110.00
VII ($500-$600).
1545............. New Technology--Level T............... ........... $650.00 ........... $130.00
VIII ($600-$700).
1546............. New Technology--Level T............... ........... $750.00 ........... $150.00
IX ($700-$800).
1547............. New Technology--Level X T............... ........... $850.00 ........... $170.00
($800-$900).
1548............. New Technology--Level T............... ........... $950.00 ........... $190.00
XI ($900-$1000).
1549............. New Technology--Level T............... ........... $1,050.00 ........... $210.00
XII ($1000-$1100).
1550............. New Technology--Level T............... ........... $1,150.00 ........... $230.00
XIII ($1100-$1200).
1551............. New Technology--Level T............... ........... $1,250.00 ........... $250.00
XIV ($1200-$1300).
1552............. New Technology--Level T............... ........... $1,350.00 ........... $270.00
XV ($1300-$1400).
1553............. New Technology--Level T............... ........... $1,450.00 ........... $290.00
XVI ($1400-$1500).
1554............. New Technology--Level T............... ........... $1,550.00 ........... $310.00
XVII ($1500-$1600).
1555............. New Technology--Level T............... ........... $1,650.00 ........... $330.00
XVIII ($1600-$1700).
1556............. New Technology--Level T............... ........... $1,750.00 ........... $350.00
XIX ($1700-$1800).
1557............. New Technology--Level T............... ........... $1,850.00 ........... $370.00
XX ($1800-$1900).
1558............. New Technology--Level T............... ........... $1,950.00 ........... $390.00
XXI ($1900-$2000).
1559............. New Technology--Level T............... ........... $2,250.00 ........... $450.00
XXII ($2000-$2500).
1560............. New Technology--Level T............... ........... $2,750.00 ........... $550.00
XXIII ($2500-$3000).
1561............. New Technology--Level T............... ........... $3,250.00 ........... $650.00
XXIV ($3000-$3500).
1562............. New Technology--Level T............... ........... $3,750.00 ........... $750.00
XXV ($3500-$4000).
1563............. New Technology--Level T............... ........... $4,250.00 ........... $850.00
XXVI ($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 T............... ........... $5,750.00 ........... $1,150.00
XXIX ($5500-$6000).
1567............. New Technology--Level T............... ........... $6,250.00 ........... $1,250.00
XXX ($6000-$6500).
1568............. New Technology--Level T............... ........... $6,750.00 ........... $1,350.00
XXXI ($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 T............... ........... $8,750.00 ........... $1,750.00
XXXV ($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).
1605............. Abciximab injection.... K............... ........... $420.17 ........... $84.03
1606............. Injection anistreplase K............... ........... $2,693.80 ........... $538.76
30 u.
1607............. Eptifibatide injection. K............... ........... $17.67 ........... $3.53
1608............. Etanercept injection... K............... ........... $167.12 ........... $33.42
1609............. Rho(D) immune globulin K............... ........... $15.62 ........... $3.12
h, sd.
1612............. Daclizumab, parenteral. K............... ........... $322.28 ........... $64.46
1613............. Trastuzumab............ K............... ........... $58.51 ........... $11.70
1629............. Nonmetabolic act d/e K............... ........... $20.22 ........... $4.04
tissue.
1630............. Hep b ig, im........... K............... ........... $122.02 ........... $24.40
1631............. Baclofen intrathecal K............... ........... $69.73 ........... $13.95
trial.
1632............. Metabolic active D/E K............... ........... $28.45 ........... $5.69
tissue.
1633............. Alefacept.............. K............... ........... $26.47 ........... $5.29
1643............. Y90 ibritumomab, rx.... K............... 235.8764 $15,023.91 ........... $3,004.78
1645............. I131 tositumomab, rx... K............... 176.8495 $11,264.25 ........... $2,252.85
1670............. Tetanus immune globulin K............... ........... $103.46 ........... $20.69
inj.
1675............. P32 Na phosphate....... K............... 1.7835 $113.60 ........... $22.72
1676............. P32 chromic phosphate.. K............... 1.8711 $119.18 ........... $23.84
1682............. Aprotonin, 10,000 kiu.. K............... ........... $2.66 ........... $0.53
1683............. Basiliximab............ K............... ........... $1,541.03 ........... $308.21
1684............. Corticorelin ovine K............... ........... $4.43 ........... $0.89
triflutal.
1685............. Darbepoetin alfa, non- K............... ........... $2.88 ........... $0.58
esrd.
1686............. Epoetin alfa, non-esrd. K............... ........... $8.97 ........... $1.79
1687............. Digoxin immune fab K............... ........... $478.88 ........... $95.78
(ovine).
1688............. Ethanolamine oleate.... K............... ........... $79.23 ........... $15.85
1689............. Fomepizole............. K............... ........... $12.80 ........... $2.56
1690............. Hemin.................. K............... ........... $7.08 ........... $1.42
1691............. Iron dextran 165 K............... ........... $11.82 ........... $2.36
injection.
1692............. Iron dextran 267 K............... ........... $10.30 ........... $2.06
injection.
1693............. Lepirudin.............. K............... ........... $159.44 ........... $31.89
1694............. Ziconotide injection... K............... ........... $6.46 ........... $1.29
[[Page 66943]]
1695............. Nesiritide injection... K............... ........... $32.95 ........... $6.59
1696............. Palifermin injection... K............... ........... $11.24 ........... $2.25
1697............. Pegaptanib sodium K............... ........... $1,035.69 ........... $207.14
injection.
1700............. Inj secretin synthetic K............... ........... $20.12 ........... $4.02
human.
1701............. Treprostinil injection. K............... ........... $55.36 ........... $11.07
1703............. Ovine, 1000 USP units.. K............... ........... $133.77 ........... $26.75
1704............. Humate-P, inj.......... K............... ........... $0.88 ........... $0.18
1705............. Factor viia............ K............... ........... $1.15 ........... $0.23
1709............. Azacitidine injection.. K............... ........... $4.35 ........... $0.87
1710............. Clofarabine injection.. K............... ........... $114.41 ........... $22.88
1711............. Vantas implant......... K............... ........... $1,412.46 ........... $282.49
1712............. Paclitaxel protein K............... ........... $8.79 ........... $1.76
bound.
1716............. Brachytx, non-str, Gold- K............... 0.5228 $33.30 ........... $6.66
198.
1717............. Brachytx, non-str, HDR K............... 2.7505 $175.19 ........... $35.04
Ir-192.
1719............. Brachytx, NS, Non-HDRIr- K............... 1.0226 $65.13 ........... $13.03
192.
1738............. Oxaliplatin............ K............... ........... $9.15 ........... $1.83
1739............. Pegademase bovine, 25 K............... ........... $197.51 ........... $39.50
iu.
1740............. Diazoxide injection.... K............... ........... $113.24 ........... $22.65
1741............. Urofollitropin, 75 iu.. K............... ........... $50.22 ........... $10.04
1821............. Interspinous implant... H............... ........... ........... ........... .
2210............. Methyldopate hcl K............... ........... $13.04 ........... $2.61
injection.
2616............. Brachytx, non- K............... 184.7105 $11,764.95 ........... $2,352.99
str,Yttrium-90.
2632............. Iodine I-125 sodium K............... 0.4325 $27.55 ........... $5.51
iodide.
2634............. Brachytx, non-str, HA, K............... 0.4858 $30.94 ........... $6.19
I-125.
2635............. Brachytx, non-str, HA, K............... 0.7366 $46.92 ........... $9.38
P-103.
2636............. Brachy linear, non- K............... 0.6600 $42.04 ........... $8.41
str,P-103.
2638............. Brachytx, stranded, I- K............... 0.7113 $45.31 ........... $9.06
125.
2639............. Brachytx, non- K............... 0.5039 $32.10 ........... $6.42
stranded,I-125.
2640............. Brachytx, stranded, P- K............... 1.0308 $65.66 ........... $13.13
103.
2641............. Brachytx, non- K............... 0.8077 $51.45 ........... $10.29
stranded,P-103.
2642............. Brachytx, stranded, C- K............... 1.5342 $97.72 ........... $19.54
131.
2643............. Brachytx, non- K............... 1.0060 $64.08 ........... $12.82
stranded,C-131.
2698............. Brachytx, stranded, NOS K............... 0.7113 $45.31 ........... $9.06
2699............. Brachytx, non-stranded, K............... 0.4858 $30.94 ........... $6.19
NOS.
2731............. Immune globulin, powder K............... ........... $26.89 ........... $5.38
2770............. Quinupristin/ K............... ........... $126.44 ........... $25.29
dalfopristin.
2940............. Somatrem injection..... K............... ........... $168.90 ........... $33.78
3030............. Sumatriptan succinate.. K............... ........... $61.27 ........... $12.25
3041............. Bivalirudin............ K............... ........... $1.84 ........... $0.37
3043............. Gamma globulin 1 CC inj K............... ........... $11.91 ........... $2.38
3050............. Sermorelin acetate K............... ........... $1.74 ........... $0.35
injection.
7000............. Amifostine............. K............... ........... $490.93 ........... $98.19
7005............. Gonadorelin hydroch.... K............... ........... $178.59 ........... $35.72
7011............. Oprelvekin injection... K............... ........... $247.02 ........... $49.40
7015............. Oral busulfan.......... K............... ........... $2.26 ........... $0.45
7028............. Fosphenytoin........... K............... ........... $5.76 ........... $1.15
7034............. Somatropin injection... K............... ........... $48.52 ........... $9.70
7035............. Teniposide............. K............... ........... $280.26 ........... $56.05
7036............. Urokinase 250,000 IU K............... ........... $453.41 ........... $90.68
inj.
7038............. Monoclonal antibodies.. K............... ........... $977.75 ........... $195.55
7041............. Tirofiban HCl.......... K............... ........... $7.56 ........... $1.51
7042............. Capecitabine, oral..... K............... ........... $4.28 ........... $0.86
7043............. Infliximab injection... K............... ........... $54.42 ........... $10.88
7045............. Inj trimetrexate K............... ........... $148.30 ........... $29.66
glucoronate.
7046............. Doxorubicin hcl K............... ........... $396.15 ........... $79.23
liposome inj.
7048............. Alteplase recombinant.. K............... ........... $33.39 ........... $6.68
7049............. Filgrastim 480 mcg K............... ........... $298.39 ........... $59.68
injection.
7051............. Leuprolide acetate K............... ........... $1,648.41 ........... $329.68
implant.
7308............. Aminolevulinic acid hcl K............... ........... $109.92 ........... $21.98
top.
8000............. Cardiac T............... 134.1189 $8,542.57 ........... $1,708.51
Electrophysiologic
Evaluation and
Ablation Composite.
8001............. LDR Prostate T............... 53.8937 $3,432.71 ........... $686.54
Brachytherapy
Composite.
8002............. Level I Extended V............... 5.5113 $351.04 ........... $70.21
Assessment &
Management Composite.
8003............. Level II Extended V............... 10.0270 $638.66 ........... $127.73
Assessment &
Management Composite.
9001............. Linezolid injection.... K............... ........... $25.17 ........... $5.03
9002............. Tenecteplase injection. K............... ........... $2,034.65 ........... $406.93
9003............. Palivizumab............ K............... ........... $810.67 ........... $162.13
9004............. Gemtuzumab ozogamicin.. K............... ........... $2,411.98 ........... $482.40
9005............. Reteplase injection.... K............... ........... $841.28 ........... $168.26
9006............. Tacrolimus injection... K............... ........... $138.64 ........... $27.73
9012............. Arsenic trioxide....... K............... ........... $34.44 ........... $6.89
9015............. Mycophenolate mofetil K............... ........... $2.66 ........... $0.53
oral.
9018............. Botulinum toxin type B. K............... ........... $8.63 ........... $1.73
9019............. Caspofungin acetate.... K............... ........... $24.05 ........... $4.81
9020............. Sirolimus, oral........ K............... ........... $7.50 ........... $1.50
9022............. IM inj interferon beta K............... ........... $118.84 ........... $23.77
1-a.
9023............. Rho d immune globulin.. K............... ........... $26.41 ........... $5.28
9024............. Amphotericin b lipid K............... ........... $10.40 ........... $2.08
complex.
9032............. Baclofen 10 MG K............... ........... $193.29 ........... $38.66
injection.
9033............. Cidofovir injection.... K............... ........... $754.39 ........... $150.88
9038............. Inj estrogen conjugate. K............... ........... $66.64 ........... $13.33
[[Page 66944]]
9042............. Glucagon hydrochloride. K............... ........... $68.84 ........... $13.77
9044............. Ibutilide fumarate K............... ........... $287.15 ........... $57.43
injection.
9046............. Iron sucrose injection. K............... ........... $0.36 ........... $0.08
9047............. Itraconazole injection. K............... ........... $39.68 ........... $7.94
9051............. Urea injection......... K............... ........... $74.16 ........... $14.83
9054............. Metabolically active K............... ........... $36.40 ........... $7.28
tissue.
9104............. Antithymocyte globuln K............... ........... $337.82 ........... $67.56
rabbit.
9108............. Thyrotropin injection.. K............... ........... $834.18 ........... $166.84
9110............. Alemtuzumab injection.. K............... ........... $549.77 ........... $109.95
9115............. Zoledronic acid........ K............... ........... $205.76 ........... $41.15
9119............. Injection, K............... ........... $2,145.12 ........... $429.02
pegfilgrastim 6mg.
9120............. Injection, Fulvestrant. K............... ........... $80.60 ........... $16.12
9121............. Injection, argatroban.. K............... ........... $18.96 ........... $3.79
9122............. Triptorelin pamoate.... K............... ........... $159.38 ........... $31.88
9124............. Daptomycin injection... K............... ........... $0.35 ........... $0.07
9125............. Risperidone, long K............... ........... $4.86 ........... $0.97
acting.
9126............. Natalizumab injection.. G............... ........... $7.51 ........... $1.50
9133............. Rabies ig, im/sc....... K............... ........... $68.22 ........... $13.64
9134............. Rabies ig, heat treated K............... ........... $71.69 ........... $14.34
9135............. Varicella-zoster ig, im K............... ........... $122.74 ........... $24.55
9137............. Bcg vaccine, percut.... K............... ........... $118.98 ........... $23.80
9139............. Rabies vaccine, im..... K............... ........... $150.80 ........... $30.16
9140............. Rabies vaccine, id..... K............... ........... $119.86 ........... $23.97
9141............. Measles-rubella K............... ........... $45.53 ........... $9.11
vaccine, sc.
9143............. Meningococcal vaccine, K............... ........... $85.29 ........... $17.06
sc.
9144............. Encephalitis vaccine, K............... ........... $98.17 ........... $19.63
sc.
9145............. Meningococcal vaccine, K............... ........... $82.00 ........... $16.40
im.
9156............. Nonmetabolic active K............... ........... $94.53 ........... $18.91
tissue.
9167............. Valrubicin, 200 mg..... K............... ........... $77.96 ........... $15.59
9207............. Bortezomib injection... K............... ........... $33.20 ........... $6.64
9208............. Agalsidase beta K............... ........... $126.00 ........... $25.20
injection.
9209............. Laronidase injection... K............... ........... $23.64 ........... $4.73
9210............. Palonosetron HCl....... K............... ........... $16.45 ........... $3.29
9213............. Pemetrexed injection... K............... ........... $44.49 ........... $8.90
9214............. Bevacizumab injection.. K............... ........... $56.93 ........... $11.39
9215............. Cetuximab injection.... K............... ........... $49.43 ........... $9.89
9216............. Abarelix injection..... K............... ........... $67.97 ........... $13.59
9217............. Leuprolide acetate K............... ........... $236.06 ........... $47.21
suspnsion.
9219............. Mycophenolic acid...... K............... ........... $2.41 ........... $0.48
9222............. Injectable human tissue K............... ........... $774.46 ........... $154.89
9224............. Galsulfase injection... K............... ........... $306.88 ........... $61.38
9225............. Fluocinolone acetonide K............... ........... $19,162.50 ........... $3,832.50
implt.
9227............. Micafungin sodium G............... ........... $1.44 ........... $0.29
injection.
9228............. Tigecycline injection.. G............... ........... $0.96 ........... $0.19
9229............. Ibandronate sodium G............... ........... $138.96 ........... $27.79
injection.
9230............. Abatacept injection.... G............... ........... $18.69 ........... $3.74
9231............. Decitabine injection... G............... ........... $26.48 ........... $5.30
9232............. Idursulfase injection.. G............... ........... $455.03 ........... $91.01
9233............. Ranibizumab injection.. G............... ........... $2,030.23 ........... $406.05
9234............. Aglucosidase alfa K............... ........... $126.00 ........... $25.20
injection.
9235............. Panitumumab injection.. G............... ........... $83.15 ........... $16.63
9236............. Eculizumab injection... G............... ........... $176.38 ........... $35.28
9238............. Inj, levetiracetam..... K............... ........... $6.30 ........... $1.26
9300............. Omalizumab injection... K............... ........... $17.12 ........... $3.42
9350............. Neuragen nerve guide, G............... ........... $482.56 ........... $96.51
per cm.
9351............. Tissuemend tissue...... G............... ........... $67.96 ........... $13.59
9500............. Platelets, irradiated.. K............... 1.9110 $121.72 ........... $24.34
9501............. Platelet pheres K............... 7.8426 $499.53 ........... $99.91
leukoreduced.
9502............. Platelet pheresis K............... 6.5581 $417.71 ........... $83.54
irradiated.
9503............. Fr frz plasma donor K............... 0.8264 $52.64 ........... $10.53
retested.
9504............. RBC deglycerolized..... K............... 5.4516 $347.23 ........... $69.45
9505............. RBC irradiated......... K............... 3.0643 $195.18 ........... $39.04
9506............. Granulocytes, pheresis K............... 21.7847 $1,387.55 ........... $277.51
unit.
9507............. Platelets, pheresis.... K............... 6.9242 $441.03 ........... $88.21
9508............. Plasma 1 donor frz w/in K............... 1.0524 $67.03 ........... $13.41
8 hr.
----------------------------------------------------------------------------------------------------------------
[[Page 66945]]
--------------------
Note: The Medicare program payment is 80 percent of the total payment
amount and beneficiary coinsurance is 20 percent of the total payment
amount, except for screening flexible sigmoidoscopies and screening
colonoscopies for which the program payment is 75 percent and the
beneficiary coinsurance is 25 percent.
* Refers to HCPCS codes designated as ``office-based,'' whose
designation as office-based is temporary because we have insufficient
claims data. We will reconsider this designation when new claims data
become available.
Addendum AA.--ASC Covered Surgical Procedures for CY 2008
[Including surgical procedures for which payment is packaged]
--------------------------------------------------------------------------------------------------------------------------------------------------------
CY 2008 CY 2008
Subject to CY 2007 ASC fully CY 2008 first
HCPCS code Short descriptor multiple Comment Payment payment implemented fully transition
procedure indicator indicator rate payment implemented year
discounting weight payment payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
0016T............ Thermotx choroid vasc Y................ ................. R2............... ........... 4.1331 $171.11 $171.11
lesion.
0017T............ Photocoagulat macular Y................ ................. R2............... ........... 4.1331 $171.11 $171.11
drusen.
0027T............ Endoscopic epidural Y................ ................. G2............... ........... 18.0518 $747.36 $747.36
lysis.
0031T............ Speculoscopy............ N................ ................. N1............... ........... ........... ........... ...........
0032T............ Speculoscopy w/direct N................ ................. N1............... ........... ........... ........... ...........
sample.
0046T............ Cath lavage, mammary Y................ ................. R2............... ........... 16.1001 $666.56 $666.56
duct(s).
0047T............ Cath lavage, mammary Y................ ................. R2............... ........... 16.1001 $666.56 $666.56
duct(s).
0062T............ Rep intradisc annulus;1 Y................ ................. G2............... ........... 29.19 $1,208.50 $1,208.50
lev.
0063T............ Rep intradisc Y................ ................. G2............... ........... 29.19 $1,208.50 $1,208.50
annulus;>1lev.
0084T............ Temp prostate urethral Y................ ................. G2............... ........... 2.0077 $83.12 $83.12
stent.
0088T............ Rf tongue base vol Y................ CH............... G2............... ........... 16.3288 $676.03 $676.03
reduxn.
0099T*........... Implant corneal ring.... Y................ ................. R2............... ........... 16.171 $669.50 $669.50
0100T............ Prosth retina Y................ ................. G2............... ........... 37.2078 $1,540.44 $1,540.44
receive&gen.
0101T............ Extracorp shockwv tx,hi Y................ ................. G2............... ........... 29.19 $1,208.50 $1,208.50
enrg.
0102T............ Extracorp shockwv Y................ ................. G2............... ........... 29.19 $1,208.50 $1,208.50
tx,anesth.
0123T............ Scleral fistulization... Y................ ................. G2............... ........... 23.1758 $959.50 $959.50
0124T*........... Conjunctival drug Y................ ................. R2............... ........... 5.1169 $211.84 $211.84
placement.
0137T............ Prostate saturation Y................ CH............... G2............... ........... 11.0338 $456.81 $456.81
sampling.
0170T............ Anorectal fistula plug Y................ CH............... G2............... ........... 30.1606 $1,248.68 $1,248.68
rpr.
0176T............ Aqu canal dilat w/o Y................ ................. A2............... $1,339.00 39.7101 $1,644.04 $1,415.26
retent.
0177T............ Aqu canal dilat w retent Y................ ................. A2............... $1,339.00 39.7101 $1,644.04 $1,415.26
0186T............ Suprachoroidal drug Y................ NI............... G2............... ........... 18.235 $754.95 $754.95
delivery.
10021............ Fna w/o image........... Y................ ................. P2............... ........... 1.1097 $45.94 $45.94
10022............ Fna w/image............. Y................ ................. G2............... ........... 4.327 $179.14 $179.14
10040............ Acne surgery............ Y................ ................. P2............... ........... 0.793 $32.83 $32.83
10060............ Drainage of skin abscess Y................ ................. P3............... ........... 1.1108 $45.99 $45.99
10061............ Drainage of skin abscess Y................ ................. P2............... ........... 1.4066 $58.23 $58.23
10080............ Drainage of pilonidal Y................ ................. P2............... ........... 1.4066 $58.23 $58.23
cyst.
10081............ Drainage of pilonidal Y................ ................. P3............... ........... 3.1023 $128.44 $128.44
cyst.
10120............ Remove foreign body..... Y................ ................. P2............... ........... 1.4066 $58.23 $58.23
10121............ Remove foreign body..... Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
10140............ Drainage of hematoma/ Y................ ................. P3............... ........... 1.6541 $68.48 $68.48
fluid.
10160............ Puncture drainage of Y................ CH............... P3............... ........... 1.4154 $58.60 $58.60
lesion.
10180............ Complex drainage, wound. Y................ ................. A2............... $446.00 18.3197 $758.45 $524.11
11000............ Debride infected skin... Y................ ................. P3............... ........... 0.5348 $22.14 $22.14
11001............ Debride infected skin Y................ ................. P3............... ........... 0.1894 $7.84 $7.84
add-on.
11010............ Debride skin, fx........ Y................ ................. A2............... $251.52 4.3039 $178.19 $233.19
11011............ Debride skin/muscle, fx. Y................ ................. A2............... $251.52 4.3039 $178.19 $233.19
11012............ Debride skin/muscle/ Y................ ................. A2............... $251.52 4.3039 $178.19 $233.19
bone, fx.
11040............ Debride skin, partial... Y................ ................. P3............... ........... 0.4937 $20.44 $20.44
11041............ Debride skin, full...... Y................ ................. P3............... ........... 0.5679 $23.51 $23.51
11042............ Debride skin/tissue..... Y................ ................. A2............... $164.42 2.6604 $110.14 $150.85
11043............ Debride tissue/muscle... Y................ ................. A2............... $164.42 2.6604 $110.14 $150.85
11044............ Debride tissue/muscle/ Y................ ................. A2............... $423.10 6.8816 $284.91 $388.55
bone.
11055............ Trim skin lesion........ Y................ ................. P3............... ........... 0.5596 $23.17 $23.17
11056............ Trim skin lesions, 2 to Y................ ................. P3............... ........... 0.6253 $25.89 $25.89
4.
11057............ Trim skin lesions, over Y................ ................. P3............... ........... 0.7077 $29.30 $29.30
4.
11100............ Biopsy, skin lesion..... Y................ ................. P2............... ........... 0.793 $32.83 $32.83
11101............ Biopsy, skin add-on..... Y................ ................. P3............... ........... 0.3046 $12.61 $12.61
11200............ Removal of skin tags.... Y................ CH............... P2............... ........... 0.793 $32.83 $32.83
11201............ Remove skin tags add-on. Y................ ................. P3............... ........... 0.1316 $5.45 $5.45
11300............ Shave skin lesion....... Y................ ................. P2............... ........... 0.793 $32.83 $32.83
11301............ Shave skin lesion....... Y................ ................. P2............... ........... 0.793 $32.83 $32.83
11302............ Shave skin lesion....... Y................ ................. P2............... ........... 0.793 $32.83 $32.83
11303............ Shave skin lesion....... Y................ ................. P3............... ........... 1.4811 $61.32 $61.32
11305............ Shave skin lesion....... Y................ ................. P3............... ........... 0.7901 $32.71 $32.71
11306............ Shave skin lesion....... Y................ CH............... P2............... ........... 0.793 $32.83 $32.83
11307............ Shave skin lesion....... Y................ ................. P2............... ........... 0.793 $32.83 $32.83
11308............ Shave skin lesion....... Y................ ................. P2............... ........... 0.793 $32.83 $32.83
11310............ Shave skin lesion....... Y................ CH............... P2............... ........... 0.793 $32.83 $32.83
11311............ Shave skin lesion....... Y................ ................. P2............... ........... 0.793 $32.83 $32.83
11312............ Shave skin lesion....... Y................ ................. P2............... ........... 0.793 $32.83 $32.83
11313............ Shave skin lesion....... Y................ CH............... P2............... ........... 0.793 $32.83 $32.83
11400............ Exc tr-ext b9+marg 0.5 < Y................ ................. P3............... ........... 1.5963 $66.09 $66.09
cm.
11401............ Exc tr-ext b9+marg 0.6-1 Y................ ................. P3............... ........... 1.7444 $72.22 $72.22
cm.
11402............ Exc tr-ext b9+marg 1.1-2 Y................ ................. P3............... ........... 1.9009 $78.70 $78.70
cm.
11403............ Exc tr-ext b9+marg 2.1-3 Y................ ................. P3............... ........... 2.0326 $84.15 $84.15
cm.
11404............ Exc tr-ext b9+marg 3.1-4 Y................ ................. A2............... $333.00 16.1001 $666.56 $416.39
cm.
11406............ Exc tr-ext b9+marg > 4.0 Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
cm.
[[Page 66946]]
11420............ Exc h-f-nk-sp b9+marg Y................ ................. P3............... ........... 1.4729 $60.98 $60.98
0.5 <.
11421............ Exc h-f-nk-sp b9+marg Y................ ................. P3............... ........... 1.7611 $72.91 $72.91
0.6-1.
11422............ Exc h-f-nk-sp b9+marg Y................ ................. P3............... ........... 1.9256 $79.72 $79.72
1.1-2.
11423............ Exc h-f-nk-sp b9+marg Y................ ................. P3............... ........... 2.156 $89.26 $89.26
2.1-3.
11424............ Exc h-f-nk-sp b9+marg Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
3.1-4.
11426............ Exc h-f-nk-sp b9+marg > Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
4 cm.
11440............ Exc face-mm b9+marg 0.5 Y................ ................. P3............... ........... 1.728 $71.54 $71.54
< cm.
11441............ Exc face-mm b9+marg 0.6- Y................ ................. P3............... ........... 1.9338 $80.06 $80.06
1 cm.
11442............ Exc face-mm b9+marg 1.1- Y................ ................. P3............... ........... 2.1313 $88.24 $88.24
2 cm.
11443............ Exc face-mm b9+marg 2.1- Y................ ................. P3............... ........... 2.3864 $98.80 $98.80
3 cm.
11444............ Exc face-mm b9+marg 3.1- Y................ ................. A2............... $333.00 8.685 $359.57 $339.64
4 cm.
11446............ Exc face-mm b9+marg > 4 Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
cm.
11450............ Removal, sweat gland Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
lesion.
11451............ Removal, sweat gland Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
lesion.
11462............ Removal, sweat gland Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
lesion.
11463............ Removal, sweat gland Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
lesion.
11470............ Removal, sweat gland Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
lesion.
11471............ Removal, sweat gland Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
lesion.
11600............ Exc tr-ext mlg+marg 0.5 Y................ ................. P3............... ........... 2.2135 $91.64 $91.64
< cm.
11601............ Exc tr-ext mlg+marg 0.6- Y................ ................. P3............... ........... 2.5263 $104.59 $104.59
1 cm.
11602............ Exc tr-ext mlg+marg 1.1- Y................ ................. P3............... ........... 2.7403 $113.45 $113.45
2 cm.
11603............ Exc tr-ext mlg+marg 2.1- Y................ ................. P3............... ........... 2.9294 $121.28 $121.28
3 cm.
11604............ Exc tr-ext mlg+marg 3.1- Y................ ................. A2............... $418.49 8.685 $359.57 $403.76
4 cm.
11606............ Exc tr-ext mlg+marg > 4 Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
cm.
11620............ Exc h-f-nk-sp mlg+marg Y................ ................. P3............... ........... 2.2384 $92.67 $92.67
0.5 <.
11621............ Exc h-f-nk-sp mlg+marg Y................ ................. P3............... ........... 2.5509 $105.61 $105.61
0.6-1.
11622............ Exc h-f-nk-sp mlg+marg Y................ ................. P3............... ........... 2.8224 $116.85 $116.85
1.1-2.
11623............ Exc h-f-nk-sp mlg+marg Y................ ................. P3............... ........... 3.061 $126.73 $126.73
2.1-3.
11624............ Exc h-f-nk-sp mlg+marg Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
3.1-4.
11626............ Exc h-f-nk-sp mlg+mar > Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
4 cm.
11640............ Exc face-mm malig+marg Y................ ................. P3............... ........... 2.3451 $97.09 $97.09
0.5 <.
11641............ Exc face-mm malig+marg Y................ ................. P3............... ........... 2.7403 $113.45 $113.45
0.6-1.
11642............ Exc face-mm malig+marg Y................ ................. P3............... ........... 3.061 $126.73 $126.73
1.1-2.
11643............ Exc face-mm malig+marg Y................ ................. P3............... ........... 3.3246 $137.64 $137.64
2.1-3.
11644............ Exc face-mm malig+marg Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
3.1-4.
11646............ Exc face-mm mlg+marg > 4 Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
cm.
11719............ Trim nail(s)............ Y................ ................. P3............... ........... 0.2551 $10.56 $10.56
11720............ Debride nail, 1-5....... Y................ ................. P3............... ........... 0.3292 $13.63 $13.63
11721............ Debride nail, 6 or more. Y................ ................. P3............... ........... 0.4031 $16.69 $16.69
11730............ Removal of nail plate... Y................ CH............... P2............... ........... 0.793 $32.83 $32.83
11732............ Remove nail plate, add- Y................ ................. P3............... ........... 0.4031 $16.69 $16.69
on.
11740............ Drain blood from under Y................ CH............... P2............... ........... 0.2963 $12.27 $12.27
nail.
11750............ Removal of nail bed..... Y................ ................. P3............... ........... 2.1065 $87.21 $87.21
11752............ Remove nail bed/finger Y................ ................. P3............... ........... 2.8965 $119.92 $119.92
tip.
11755............ Biopsy, nail unit....... Y................ ................. P3............... ........... 1.4729 $60.98 $60.98
11760............ Repair of nail bed...... Y................ ................. G2............... ........... 2.1051 $87.15 $87.15
11762............ Reconstruction of nail Y................ CH............... P3............... ........... 2.7072 $112.08 $112.08
bed.
11765............ Excision of nail fold, Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
toe.
11770............ Removal of pilonidal Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
lesion.
11771............ Removal of pilonidal Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
lesion.
11772............ Removal of pilonidal Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
lesion.
11900............ Injection into skin Y................ ................. P3............... ........... 0.6418 $26.57 $26.57
lesions.
11901............ Added skin lesions Y................ ................. P3............... ........... 0.6831 $28.28 $28.28
injection.
11920............ Correct skin color Y................ ................. P2............... ........... 2.1051 $87.15 $87.15
defects.
11921............ Correct skin color Y................ ................. P2............... ........... 2.1051 $87.15 $87.15
defects.
11922............ Correct skin color Y................ ................. P3............... ........... 0.8476 $35.09 $35.09
defects.
11950............ Therapy for contour Y................ ................. P3............... ........... 0.8311 $34.41 $34.41
defects.
11951............ Therapy for contour Y................ ................. P3............... ........... 0.9792 $40.54 $40.54
defects.
11952............ Therapy for contour Y................ CH............... P2............... ........... 1.2792 $52.96 $52.96
defects.
11954............ Therapy for contour Y................ ................. P2............... ........... 1.2792 $52.96 $52.96
defects.
11960............ Insert tissue Y................ ................. A2............... $446.00 20.2069 $836.59 $543.65
expander(s).
11970............ Replace tissue expander. Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
11971............ Remove tissue Y................ ................. A2............... $333.00 21.1098 $873.97 $468.24
expander(s).
11976............ Removal of contraceptive Y................ ................. P3............... ........... 1.4154 $58.60 $58.60
cap.
11980............ Implant hormone N................ ................. P2............... ........... 0.631 $26.12 $26.12
pellet(s).
11981............ Insert drug implant N................ ................. P2............... ........... 0.631 $26.12 $26.12
device.
11982............ Remove drug implant N................ ................. P2............... ........... 0.631 $26.12 $26.12
device.
11983............ Remove/insert drug N................ ................. P2............... ........... 0.631 $26.12 $26.12
implant.
12001............ Repair superficial Y................ ................. P2............... ........... 1.2792 $52.96 $52.96
wound(s).
12002............ Repair superficial Y................ ................. P2............... ........... 1.2792 $52.96 $52.96
wound(s).
12004............ Repair superficial Y................ ................. P2............... ........... 1.2792 $52.96 $52.96
wound(s).
12005............ Repair superficial Y................ ................. A2............... $91.24 1.2792 $52.96 $81.67
wound(s).
12006............ Repair superficial Y................ ................. A2............... $91.24 1.2792 $52.96 $81.67
wound(s).
[[Page 66947]]
12007............ Repair superficial Y................ ................. A2............... $91.24 1.2792 $52.96 $81.67
wound(s).
12011............ Repair superficial Y................ ................. P2............... ........... 1.2792 $52.96 $52.96
wound(s).
12013............ Repair superficial Y................ ................. P2............... ........... 1.2792 $52.96 $52.96
wound(s).
12014............ Repair superficial Y................ ................. P2............... ........... 1.2792 $52.96 $52.96
wound(s).
12015............ Repair superficial Y................ ................. G2............... ........... 1.2792 $52.96 $52.96
wound(s).
12016............ Repair superficial Y................ ................. A2............... $91.24 1.2792 $52.96 $81.67
wound(s).
12017............ Repair superficial Y................ ................. A2............... $91.24 1.2792 $52.96 $81.67
wound(s).
12018............ Repair superficial Y................ ................. A2............... $91.24 1.2792 $52.96 $81.67
wound(s).
12020............ Closure of split wound.. Y................ ................. A2............... $91.24 4.5263 $187.39 $115.28
12021............ Closure of split wound.. Y................ ................. A2............... $91.24 4.5263 $187.39 $115.28
12031............ Layer closure of Y................ ................. P2............... ........... 2.1051 $87.15 $87.15
wound(s).
12032............ Layer closure of Y................ ................. P2............... ........... 2.1051 $87.15 $87.15
wound(s).
12034............ Layer closure of Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
wound(s).
12035............ Layer closure of Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
wound(s).
12036............ Layer closure of Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
wound(s).
12037............ Layer closure of Y................ ................. A2............... $323.28 2.1051 $87.15 $264.25
wound(s).
12041............ Layer closure of Y................ ................. P2............... ........... 2.1051 $87.15 $87.15
wound(s).
12042............ Layer closure of Y................ ................. P2............... ........... 2.1051 $87.15 $87.15
wound(s).
12044............ Layer closure of Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
wound(s).
12045............ Layer closure of Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
wound(s).
12046............ Layer closure of Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
wound(s).
12047............ Layer closure of Y................ ................. A2............... $323.28 2.1051 $87.15 $264.25
wound(s).
12051............ Layer closure of Y................ ................. P2............... ........... 2.1051 $87.15 $87.15
wound(s).
12052............ Layer closure of Y................ ................. P2............... ........... 2.1051 $87.15 $87.15
wound(s).
12053............ Layer closure of Y................ ................. P2............... ........... 2.1051 $87.15 $87.15
wound(s).
12054............ Layer closure of Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
wound(s).
12055............ Layer closure of Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
wound(s).
12056............ Layer closure of Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
wound(s).
12057............ Layer closure of Y................ ................. A2............... $323.28 2.1051 $87.15 $264.25
wound(s).
13100............ Repair of wound or Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
lesion.
13101............ Repair of wound or Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
lesion.
13102............ Repair wound/lesion add- Y................ ................. A2............... $91.24 4.5263 $187.39 $115.28
on.
13120............ Repair of wound or Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
lesion.
13121............ Repair of wound or Y................ ................. A2............... $91.24 4.5263 $187.39 $115.28
lesion.
13122............ Repair wound/lesion add- Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
on.
13131............ Repair of wound or Y................ ................. A2............... $91.24 4.5263 $187.39 $115.28
lesion.
13132............ Repair of wound or Y................ ................. A2............... $91.24 4.5263 $187.39 $115.28
lesion.
13133............ Repair wound/lesion add- Y................ ................. A2............... $91.24 4.5263 $187.39 $115.28
on.
13150............ Repair of wound or Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
lesion.
13151............ Repair of wound or Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
lesion.
13152............ Repair of wound or Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
lesion.
13153............ Repair wound/lesion add- Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
on.
13160............ Late closure of wound... Y................ ................. A2............... $446.00 20.2069 $836.59 $543.65
14000............ Skin tissue Y................ ................. A2............... $446.00 15.0458 $622.91 $490.23
rearrangement.
14001............ Skin tissue Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
rearrangement.
14020............ Skin tissue Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
rearrangement.
14021............ Skin tissue Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
rearrangement.
14040............ Skin tissue Y................ ................. A2............... $446.00 15.0458 $622.91 $490.23
rearrangement.
14041............ Skin tissue Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
rearrangement.
14060............ Skin tissue Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
rearrangement.
14061............ Skin tissue Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
rearrangement.
14300............ Skin tissue Y................ ................. A2............... $630.00 20.2069 $836.59 $681.65
rearrangement.
14350............ Skin tissue Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
rearrangement.
15002............ Wnd prep, ch/inf, trk/ Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
arm/lg.
15003............ Wnd prep, ch/inf addl Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
100 cm.
15004............ Wnd prep ch/inf, f/n/hf/ Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
g.
15005............ Wnd prep, f/n/hf/g, addl Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
cm.
15040............ Harvest cultured skin Y................ ................. A2............... $91.24 2.1051 $87.15 $90.22
graft.
15050............ Skin pinch graft........ Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
15100............ Skin splt grft, trnk/arm/ Y................ ................. A2............... $446.00 20.2069 $836.59 $543.65
leg.
15101............ Skin splt grft t/a/l, Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
add-on.
15110............ Epidrm autogrft trnk/arm/ Y................ ................. A2............... $446.00 4.5263 $187.39 $381.35
leg.
15111............ Epidrm autogrft t/a/l Y................ ................. A2............... $333.00 4.5263 $187.39 $296.60
add-on.
15115............ Epidrm a-grft face/nck/ Y................ ................. A2............... $446.00 4.5263 $187.39 $381.35
hf/g.
15116............ Epidrm a-grft f/n/hf/g Y................ ................. A2............... $333.00 4.5263 $187.39 $296.60
addl.
15120............ Skn splt a-grft fac/nck/ Y................ ................. A2............... $446.00 20.2069 $836.59 $543.65
hf/g.
15121............ Skn splt a-grft f/n/hf/g Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
add.
15130............ Derm autograft, trnk/arm/ Y................ ................. A2............... $446.00 15.0458 $622.91 $490.23
leg.
15131............ Derm autograft t/a/l add- Y................ ................. A2............... $333.00 15.0458 $622.91 $405.48
on.
15135............ Derm autograft face/nck/ Y................ ................. A2............... $446.00 15.0458 $622.91 $490.23
hf/g.
15136............ Derm autograft, f/n/hf/g Y................ ................. A2............... $333.00 15.0458 $622.91 $405.48
add.
15150............ Cult epiderm grft t/arm/ Y................ ................. A2............... $446.00 4.5263 $187.39 $381.35
leg.
15151............ Cult epiderm grft t/a/l Y................ ................. A2............... $333.00 4.5263 $187.39 $296.60
addl.
[[Page 66948]]
15152............ Cult epiderm graft t/a/l Y................ ................. A2............... $333.00 4.5263 $187.39 $296.60
+%.
15155............ Cult epiderm graft, f/n/ Y................ ................. A2............... $446.00 4.5263 $187.39 $381.35
hf/g.
15156............ Cult epidrm grft f/n/hfg Y................ ................. A2............... $333.00 4.5263 $187.39 $296.60
add.
15157............ Cult epiderm grft f/n/ Y................ ................. A2............... $333.00 4.5263 $187.39 $296.60
hfg +%.
15200............ Skin full graft, trunk.. Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
15201............ Skin full graft trunk Y................ ................. A2............... $323.28 15.0458 $622.91 $398.19
add-on.
15220............ Skin full graft sclp/arm/ Y................ ................. A2............... $446.00 15.0458 $622.91 $490.23
leg.
15221............ Skin full graft add-on.. Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
15240............ Skin full grft face/ Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
genit/hf.
15241............ Skin full graft add-on.. Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
15260............ Skin full graft een & Y................ ................. A2............... $446.00 15.0458 $622.91 $490.23
lips.
15261............ Skin full graft add-on.. Y................ ................. A2............... $323.28 15.0458 $622.91 $398.19
15300............ Apply skinallogrft, t/ Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
arm/lg.
15301............ Apply sknallogrft t/a/l Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
addl.
15320............ Apply skin allogrft f/n/ Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
hf/g.
15321............ Aply sknallogrft f/n/hfg Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
add.
15330............ Aply acell alogrft t/arm/ Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
leg.
15331............ Aply acell grft t/a/l Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
add-on.
15335............ Apply acell graft, f/n/ Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
hf/g.
15336............ Aply acell grft f/n/hf/g Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
add.
15340............ Apply cult skin Y................ CH............... G2............... ........... 2.1051 $87.15 $87.15
substitute.
15341............ Apply cult skin sub add- Y................ ................. G2............... ........... 2.1051 $87.15 $87.15
on.
15360............ Apply cult derm sub, t/a/ Y................ ................. G2............... ........... 2.1051 $87.15 $87.15
l.
15361............ Aply cult derm sub t/a/l Y................ ................. G2............... ........... 2.1051 $87.15 $87.15
add.
15365............ Apply cult derm sub f/n/ Y................ ................. G2............... ........... 2.1051 $87.15 $87.15
hf/g.
15366............ Apply cult derm f/hf/g Y................ ................. G2............... ........... 2.1051 $87.15 $87.15
add.
15400............ Apply skin xenograft, t/ Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
a/l.
15401............ Apply skn xenogrft t/a/l Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
add.
15420............ Apply skin xgraft, f/n/ Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
hf/g.
15421............ Apply skn xgrft f/n/hf/g Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
add.
15430............ Apply acellular Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
xenograft.
15431............ Apply acellular xgraft Y................ ................. A2............... $323.28 4.5263 $187.39 $289.31
add.
15570............ Form skin pedicle flap.. Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15572............ Form skin pedicle flap.. Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15574............ Form skin pedicle flap.. Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15576............ Form skin pedicle flap.. Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15600............ Skin graft.............. Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15610............ Skin graft.............. Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15620............ Skin graft.............. Y................ ................. A2............... $630.00 20.2069 $836.59 $681.65
15630............ Skin graft.............. Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15650............ Transfer skin pedicle Y................ ................. A2............... $717.00 20.2069 $836.59 $746.90
flap.
15731............ Forehead flap w/vasc Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
pedicle.
15732............ Muscle-skin graft, head/ Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
neck.
15734............ Muscle-skin graft, trunk Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15736............ Muscle-skin graft, arm.. Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15738............ Muscle-skin graft, leg.. Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15740............ Island pedicle flap Y................ ................. A2............... $446.00 15.0458 $622.91 $490.23
graft.
15750............ Neurovascular pedicle Y................ ................. A2............... $446.00 20.2069 $836.59 $543.65
graft.
15760............ Composite skin graft.... Y................ ................. A2............... $446.00 20.2069 $836.59 $543.65
15770............ Derma-fat-fascia graft.. Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15775............ Hair transplant punch Y................ ................. A2............... $323.28 1.2792 $52.96 $255.70
grafts.
15776............ Hair transplant punch Y................ ................. A2............... $323.28 1.2792 $52.96 $255.70
grafts.
15780............ Abrasion treatment of Y................ ................. P3............... ........... 9.3563 $387.36 $387.36
skin.
15781............ Abrasion treatment of Y................ ................. P2............... ........... 4.3039 $178.19 $178.19
skin.
15782............ Abrasion treatment of Y................ ................. P2............... ........... 4.3039 $178.19 $178.19
skin.
15783............ Abrasion treatment of Y................ ................. P2............... ........... 2.6604 $110.14 $110.14
skin.
15786............ Abrasion, lesion, single Y................ ................. P2............... ........... 0.793 $32.83 $32.83
15787............ Abrasion, lesions, add- Y................ ................. P3............... ........... 0.7901 $32.71 $32.71
on.
15788............ Chemical peel, face, Y................ ................. P2............... ........... 0.793 $32.83 $32.83
epiderm.
15789............ Chemical peel, face, Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
dermal.
15792............ Chemical peel, nonfacial Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
15793............ Chemical peel, nonfacial Y................ ................. P2............... ........... 0.793 $32.83 $32.83
15819............ Plastic surgery, neck... Y................ ................. G2............... ........... 2.1051 $87.15 $87.15
15820............ Revision of lower eyelid Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15821............ Revision of lower eyelid Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15822............ Revision of upper eyelid Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15823............ Revision of upper eyelid Y................ ................. A2............... $717.00 20.2069 $836.59 $746.90
15824............ Removal of forehead Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
wrinkles.
15825............ Removal of neck wrinkles Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15826............ Removal of brow wrinkles Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15828............ Removal of face wrinkles Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15829............ Removal of skin wrinkles Y................ ................. A2............... $717.00 20.2069 $836.59 $746.90
15830............ Exc skin abd............ Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
[[Page 66949]]
15832............ Excise excessive skin Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
tissue.
15833............ Excise excessive skin Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
tissue.
15834............ Excise excessive skin Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
tissue.
15835............ Excise excessive skin Y................ ................. A2............... $323.28 21.1098 $873.97 $460.95
tissue.
15836............ Excise excessive skin Y................ ................. A2............... $510.00 16.1001 $666.56 $549.14
tissue.
15837............ Excise excessive skin Y................ ................. G2............... ........... 16.1001 $666.56 $666.56
tissue.
15838............ Excise excessive skin Y................ ................. G2............... ........... 16.1001 $666.56 $666.56
tissue.
15839............ Excise excessive skin Y................ ................. A2............... $510.00 16.1001 $666.56 $549.14
tissue.
15840............ Graft for face nerve Y................ ................. A2............... $630.00 20.2069 $836.59 $681.65
palsy.
15841............ Graft for face nerve Y................ ................. A2............... $630.00 20.2069 $836.59 $681.65
palsy.
15842............ Flap for face nerve Y................ ................. G2............... ........... 20.2069 $836.59 $836.59
palsy.
15845............ Skin and muscle repair, Y................ ................. A2............... $630.00 20.2069 $836.59 $681.65
face.
15847............ Exc skin abd add-on..... Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
15850............ Removal of sutures...... Y................ ................. G2............... ........... 2.6604 $110.14 $110.14
15851............ Removal of sutures...... Y................ ................. P3............... ........... 1.2343 $51.10 $51.10
15852............ Dressing change not for N................ ................. G2............... ........... 0.631 $26.12 $26.12
burn.
15860............ Test for blood flow in N................ ................. G2............... ........... 0.631 $26.12 $26.12
graft.
15876............ Suction assisted Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
lipectomy.
15877............ Suction assisted Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
lipectomy.
15878............ Suction assisted Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
lipectomy.
15879............ Suction assisted Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
lipectomy.
15920............ Removal of tail bone Y................ ................. A2............... $251.52 4.3039 $178.19 $233.19
ulcer.
15922............ Removal of tail bone Y................ ................. A2............... $630.00 20.2069 $836.59 $681.65
ulcer.
15931............ Remove sacrum pressure Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
sore.
15933............ Remove sacrum pressure Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
sore.
15934............ Remove sacrum pressure Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
sore.
15935............ Remove sacrum pressure Y................ ................. A2............... $630.00 20.2069 $836.59 $681.65
sore.
15936............ Remove sacrum pressure Y................ ................. A2............... $630.00 15.0458 $622.91 $628.23
sore.
15937............ Remove sacrum pressure Y................ ................. A2............... $630.00 20.2069 $836.59 $681.65
sore.
15940............ Remove hip pressure sore Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
15941............ Remove hip pressure sore Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
15944............ Remove hip pressure sore Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
15945............ Remove hip pressure sore Y................ ................. A2............... $630.00 20.2069 $836.59 $681.65
15946............ Remove hip pressure sore Y................ ................. A2............... $630.00 20.2069 $836.59 $681.65
15950............ Remove thigh pressure Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
sore.
15951............ Remove thigh pressure Y................ ................. A2............... $630.00 21.1098 $873.97 $690.99
sore.
15952............ Remove thigh pressure Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
sore.
15953............ Remove thigh pressure Y................ ................. A2............... $630.00 15.0458 $622.91 $628.23
sore.
15956............ Remove thigh pressure Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
sore.
15958............ Remove thigh pressure Y................ ................. A2............... $630.00 15.0458 $622.91 $628.23
sore.
16000............ Initial treatment of Y................ ................. P3............... ........... 0.65 $26.91 $26.91
burn(s).
16020............ Dress/debrid p-thick Y................ ................. P3............... ........... 0.9874 $40.88 $40.88
burn, s.
16025............ Dress/debrid p-thick Y................ ................. A2............... $67.11 2.6604 $110.14 $77.87
burn, m.
16030............ Dress/debrid p-thick Y................ ................. A2............... $99.83 2.6604 $110.14 $102.41
burn, l.
16035............ Incision of burn scab, Y................ ................. G2............... ........... 2.6604 $110.14 $110.14
initi.
17000............ Destruct premalg lesion. Y................ ................. P2............... ........... 0.793 $32.83 $32.83
17003............ Destruct premalg les, 2- Y................ ................. P3............... ........... 0.0906 $3.75 $3.75
14.
17004............ Destroy premlg lesions Y................ ................. P3............... ........... 1.9502 $80.74 $80.74
15+.
17106............ Destruction of skin Y................ ................. P2............... ........... 2.6604 $110.14 $110.14
lesions.
17107............ Destruction of skin Y................ ................. P2............... ........... 2.6604 $110.14 $110.14
lesions.
17108............ Destruction of skin Y................ ................. P2............... ........... 2.6604 $110.14 $110.14
lesions.
17110............ Destruct b9 lesion, 1-14 Y................ ................. P2............... ........... 0.793 $32.83 $32.83
17111............ Destruct lesion, 15 or Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
more.
17250............ Chemical cautery, tissue Y................ ................. P3............... ........... 1.0451 $43.27 $43.27
17260............ Destruction of skin Y................ ................. P3............... ........... 1.1026 $45.65 $45.65
lesions.
17261............ Destruction of skin Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
lesions.
17262............ Destruction of skin Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
lesions.
17263............ Destruction of skin Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
lesions.
17264............ Destruction of skin Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
lesions.
17266............ Destruction of skin Y................ ................. P3............... ........... 2.4685 $102.20 $102.20
lesions.
17270............ Destruction of skin Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
lesions.
17271............ Destruction of skin Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
lesions.
17272............ Destruction of skin Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
lesions.
17273............ Destruction of skin Y................ CH............... P3............... ........... 2.2299 $92.32 $92.32
lesions.
17274............ Destruction of skin Y................ ................. P3............... ........... 2.5345 $104.93 $104.93
lesions.
17276............ Destruction of skin Y................ ................. P2............... ........... 2.6604 $110.14 $110.14
lesions.
17280............ Destruction of skin Y................ CH............... P2............... ........... 1.4595 $60.42 $60.42
lesions.
17281............ Destruction of skin Y................ CH............... P3............... ........... 1.9091 $79.04 $79.04
lesions.
17282............ Destruction of skin Y................ CH............... P3............... ........... 2.1724 $89.94 $89.94
lesions.
17283............ Destruction of skin Y................ CH............... P3............... ........... 2.5098 $103.91 $103.91
lesions.
17284............ Destruction of skin Y................ ................. P2............... ........... 2.6604 $110.14 $110.14
lesions.
17286............ Destruction of skin Y................ ................. P2............... ........... 2.6604 $110.14 $110.14
lesions.
17311............ Mohs, 1 stage, h/n/hf/g. Y................ ................. P2............... ........... 3.6321 $150.37 $150.37
[[Page 66950]]
17312............ Mohs addl stage......... Y................ ................. P2............... ........... 3.6321 $150.37 $150.37
17313............ Mohs, 1 stage, t/a/l.... Y................ ................. P2............... ........... 3.6321 $150.37 $150.37
17314............ Mohs, addl stage, t/a/l. Y................ ................. P2............... ........... 3.6321 $150.37 $150.37
17315............ Mohs surg, addl block... Y................ ................. P3............... ........... 0.9381 $38.84 $38.84
17340............ Cryotherapy of skin..... Y................ ................. P3............... ........... 0.2961 $12.26 $12.26
17360............ Skin peel therapy....... Y................ ................. P2............... ........... 0.793 $32.83 $32.83
17380............ Hair removal by Y................ ................. R2............... ........... 0.793 $32.83 $32.83
electrolysis.
19000............ Drainage of breast Y................ ................. P3............... ........... 1.6046 $66.43 $66.43
lesion.
19001............ Drain breast lesion add- Y................ ................. P3............... ........... 0.2058 $8.52 $8.52
on.
19020............ Incision of breast Y................ ................. A2............... $446.00 18.3197 $758.45 $524.11
lesion.
19030............ Injection for breast x- N................ ................. N1............... ........... ........... ........... ...........
ray.
19100............ Bx breast percut w/o Y................ ................. A2............... $240.00 4.327 $179.14 $224.79
image.
19101............ Biopsy of breast, open.. Y................ ................. A2............... $446.00 20.6417 $854.59 $548.15
19102............ Bx breast percut w/image Y................ ................. A2............... $240.00 7.1147 $294.56 $253.64
19103............ Bx breast percut w/ Y................ ................. A2............... $395.77 13.5764 $562.08 $437.35
device.
19105............ Cryosurg ablate fa, each Y................ ................. G2............... ........... 31.7134 $1,312.97 $1,312.97
19110............ Nipple exploration...... Y................ ................. A2............... $446.00 20.6417 $854.59 $548.15
19112............ Excise breast duct Y................ ................. A2............... $510.00 20.6417 $854.59 $596.15
fistula.
19120............ Removal of breast lesion Y................ ................. A2............... $510.00 20.6417 $854.59 $596.15
19125............ Excision, breast lesion. Y................ ................. A2............... $510.00 20.6417 $854.59 $596.15
19126............ Excision, addl breast Y................ ................. A2............... $510.00 20.6417 $854.59 $596.15
lesion.
19290............ Place needle wire, N................ ................. N1............... ........... ........... ........... ...........
breast.
19291............ Place needle wire, N................ ................. N1............... ........... ........... ........... ...........
breast.
19295............ Place breast clip, N................ CH............... N1............... ........... ........... ........... ...........
percut.
19296............ Place po breast cath for Y................ ................. A2............... $1,339.00 56.5774 $2,342.36 $1,589.84
rad.
19297............ Place breast cath for Y................ ................. A2............... $1,339.00 56.5774 $2,342.36 $1,589.84
rad.
19298............ Place breast rad tube/ Y................ ................. A2............... $1,339.00 56.5774 $2,342.36 $1,589.84
caths.
19300............ Removal of breast tissue Y................ ................. A2............... $630.00 20.6417 $854.59 $686.15
19301............ Partical mastectomy..... Y................ ................. A2............... $510.00 20.6417 $854.59 $596.15
19302............ P-mastectomy w/ln Y................ ................. A2............... $995.00 39.8191 $1,648.55 $1,158.39
removal.
19303............ Mast, simple, complete.. Y................ ................. A2............... $630.00 31.7134 $1,312.97 $800.74
19304............ Mast, subq.............. Y................ ................. A2............... $630.00 31.7134 $1,312.97 $800.74
19316............ Suspension of breast.... Y................ ................. A2............... $630.00 31.7134 $1,312.97 $800.74
19318............ Reduction of large Y................ ................. A2............... $630.00 39.8191 $1,648.55 $884.64
breast.
19324............ Enlarge breast.......... Y................ ................. A2............... $630.00 39.8191 $1,648.55 $884.64
19325............ Enlarge breast with Y................ ................. A2............... $1,339.00 56.5774 $2,342.36 $1,589.84
implant.
19328............ Removal of breast Y................ ................. A2............... $333.00 31.7134 $1,312.97 $577.99
implant.
19330............ Removal of implant Y................ ................. A2............... $333.00 31.7134 $1,312.97 $577.99
material.
19340............ Immediate breast Y................ ................. A2............... $446.00 39.8191 $1,648.55 $746.64
prosthesis.
19342............ Delayed breast Y................ ................. A2............... $510.00 56.5774 $2,342.36 $968.09
prosthesis.
19350............ Breast reconstruction... Y................ ................. A2............... $630.00 20.6417 $854.59 $686.15
19355............ Correct inverted Y................ ................. A2............... $630.00 31.7134 $1,312.97 $800.74
nipple(s).
19357............ Breast reconstruction... Y................ ................. A2............... $717.00 56.5774 $2,342.36 $1,123.34
19366............ Breast reconstruction... Y................ ................. A2............... $717.00 31.7134 $1,312.97 $865.99
19370............ Surgery of breast Y................ ................. A2............... $630.00 31.7134 $1,312.97 $800.74
capsule.
19371............ Removal of breast Y................ ................. A2............... $630.00 31.7134 $1,312.97 $800.74
capsule.
19380............ Revise breast Y................ ................. A2............... $717.00 39.8191 $1,648.55 $949.89
reconstruction.
19396............ Design custom breast Y................ ................. G2............... ........... 31.7134 $1,312.97 $1,312.97
implant.
20000............ Incision of abscess..... Y................ ................. P2............... ........... 1.4066 $58.23 $58.23
20005............ Incision of deep abscess Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
20103............ Explore wound, extremity Y................ ................. G2............... ........... 9.6341 $398.86 $398.86
20150............ Excise epiphyseal bar... Y................ ................. G2............... ........... 42.985 $1,779.62 $1,779.62
20200............ Muscle biopsy........... Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
20205............ Deep muscle biopsy...... Y................ ................. A2............... $510.00 16.1001 $666.56 $549.14
20206............ Needle biopsy, muscle... Y................ ................. A2............... $240.00 7.1147 $294.56 $253.64
20220............ Bone biopsy, trocar/ Y................ ................. A2............... $251.52 8.685 $359.57 $278.53
needle.
20225............ Bone biopsy, trocar/ Y................ ................. A2............... $418.49 8.685 $359.57 $403.76
needle.
20240............ Bone biopsy, excisional. Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
20245............ Bone biopsy, excisional. Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
20250............ Open bone biopsy........ Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
20251............ Open bone biopsy........ Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
20500............ Injection of sinus tract Y................ ................. P3............... ........... 1.4811 $61.32 $61.32
20501............ Inject sinus tract for x- N................ ................. N1............... ........... ........... ........... ...........
ray.
20520............ Removal of foreign body. Y................ ................. P3............... ........... 2.2712 $94.03 $94.03
20525............ Removal of foreign body. Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
20526............ Ther injection, carp Y................ ................. P3............... ........... 0.7323 $30.32 $30.32
tunnel.
20550............ Inj tendon sheath/ Y................ ................. P3............... ........... 0.5514 $22.83 $22.83
ligament.
20551............ Inj tendon origin/ Y................ ................. P3............... ........... 0.5432 $22.49 $22.49
insertion.
20552............ Inj trigger point, 1/2 Y................ ................. P3............... ........... 0.5348 $22.14 $22.14
muscl.
20553............ Inject trigger points, =/ Y................ ................. P3............... ........... 0.6007 $24.87 $24.87
> 3.
20555............ Place ndl musc/tis for Y................ NI............... G2............... ........... 29.19 $1,208.50 $1,208.50
rt.
20600............ Drain/inject, joint/ Y................ ................. P3............... ........... 0.5432 $22.49 $22.49
bursa.
20605............ Drain/inject, joint/ Y................ ................. P3............... ........... 0.6171 $25.55 $25.55
bursa.
[[Page 66951]]
20610............ Drain/inject, joint/ Y................ ................. P3............... ........... 0.8311 $34.41 $34.41
bursa.
20612............ Aspirate/inj ganglion Y................ ................. P3............... ........... 0.5761 $23.85 $23.85
cyst.
20615............ Treatment of bone cyst.. Y................ CH............... P3............... ........... 2.5591 $105.95 $105.95
20650............ Insert and remove bone Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
pin.
20662............ Application of pelvis Y................ ................. R2............... ........... 21.2689 $880.55 $880.55
brace.
20663............ Application of thigh Y................ ................. R2............... ........... 21.2689 $880.55 $880.55
brace.
20665............ Removal of fixation N................ ................. G2............... ........... 0.631 $26.12 $26.12
device.
20670............ Removal of support Y................ ................. A2............... $333.00 16.1001 $666.56 $416.39
implant.
20680............ Removal of support Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
implant.
20690............ Apply bone fixation Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
device.
20692............ Apply bone fixation Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
device.
20693............ Adjust bone fixation Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
device.
20694............ Remove bone fixation Y................ ................. A2............... $333.00 21.2689 $880.55 $469.89
device.
20822............ Replantation digit, Y................ ................. G2............... ........... 26.3105 $1,089.28 $1,089.28
complete.
20900............ Removal of bone for Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
graft.
20902............ Removal of bone for Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
graft.
20910............ Remove cartilage for Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
graft.
20912............ Remove cartilage for Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
graft.
20920............ Removal of fascia for Y................ ................. A2............... $630.00 15.0458 $622.91 $628.23
graft.
20922............ Removal of fascia for Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
graft.
20924............ Removal of tendon for Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
graft.
20926............ Removal of tissue for Y................ ................. A2............... $630.00 4.5263 $187.39 $519.35
graft.
20950............ Fluid pressure, muscle.. Y................ ................. G2............... ........... 1.4066 $58.23 $58.23
20972............ Bone/skin graft, Y................ ................. G2............... ........... 44.2687 $1,832.77 $1,832.77
metatarsal.
20973............ Bone/skin graft, great Y................ ................. R2............... ........... 44.2687 $1,832.77 $1,832.77
toe.
20975............ Electrical bone N................ CH............... N1............... ........... ........... ........... ...........
stimulation.
20979............ Us bone stimulation..... N................ ................. P3............... ........... 0.5843 $24.19 $24.19
20982............ Ablate, bone tumor(s) Y................ ................. G2............... ........... 42.985 $1,779.62 $1,779.62
perq.
20985............ Cptr-asst dir ms px..... N................ NI............... N1............... ........... ........... ........... ...........
20986............ Cptr-asst dir ms px io N................ NI............... N1............... ........... ........... ........... ...........
img.
20987............ Cptr-asst dir ms px pre N................ NI............... N1............... ........... ........... ........... ...........
img.
21010............ Incision of jaw joint... Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
21015............ Resection of facial Y................ ................. A2............... $510.00 16.3288 $676.03 $551.51
tumor.
21025............ Excision of bone, lower Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
jaw.
21026............ Excision of facial Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
bone(s).
21029............ Contour of face bone Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
lesion.
21030............ Excise max/zygoma b9 Y................ ................. P3............... ........... 5.5627 $230.30 $230.30
tumor.
21031............ Remove exostosis, Y................ ................. P3............... ........... 4.5588 $188.74 $188.74
mandible.
21032............ Remove exostosis, Y................ ................. P3............... ........... 4.6823 $193.85 $193.85
maxilla.
21034............ Excise max/zygoma mlg Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
tumor.
21040............ Excise mandible lesion.. Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
21044............ Removal of jaw bone Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
lesion.
21046............ Remove mandible cyst Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
complex.
21047............ Excise lwr jaw cyst w/ Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
repair.
21048............ Remove maxilla cyst Y................ ................. R2............... ........... 39.8776 $1,650.97 $1,650.97
complex.
21050............ Removal of jaw joint.... Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
21060............ Remove jaw joint Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
cartilage.
21070............ Remove coronoid process. Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
21073*........... Mnpj of tmj w/anesth.... Y................ NI............... P3............... ........... 4.526 $187.38 $187.38
21076............ Prepare face/oral Y................ ................. P3............... ........... 8.3769 $346.81 $346.81
prosthesis.
21077............ Prepare face/oral Y................ ................. P3............... ........... 20.457 $846.94 $846.94
prosthesis.
21079............ Prepare face/oral Y................ ................. P3............... ........... 14.5815 $603.69 $603.69
prosthesis.
21080............ Prepare face/oral Y................ ................. P3............... ........... 16.7129 $691.93 $691.93
prosthesis.
21081............ Prepare face/oral Y................ ................. P3............... ........... 15.3467 $635.37 $635.37
prosthesis.
21082............ Prepare face/oral Y................ ................. P3............... ........... 14.0796 $582.91 $582.91
prosthesis.
21083............ Prepare face/oral Y................ ................. P3............... ........... 13.8492 $573.37 $573.37
prosthesis.
21084............ Prepare face/oral Y................ ................. P3............... ........... 16.1532 $668.76 $668.76
prosthesis.
21085............ Prepare face/oral Y................ ................. P3............... ........... 6.254 $258.92 $258.92
prosthesis.
21086............ Prepare face/oral Y................ ................. P3............... ........... 15.067 $623.79 $623.79
prosthesis.
21087............ Prepare face/oral Y................ ................. P3............... ........... 14.9354 $618.34 $618.34
prosthesis.
21088............ Prepare face/oral Y................ ................. R2............... ........... 39.8776 $1,650.97 $1,650.97
prosthesis.
21100............ Maxillofacial fixation.. Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
21110............ Interdental fixation.... Y................ ................. P2............... ........... 7.4474 $308.33 $308.33
21116............ Injection, jaw joint x- N................ ................. N1............... ........... ........... ........... ...........
ray.
21120............ Reconstruction of chin.. Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
21121............ Reconstruction of chin.. Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
21122............ Reconstruction of chin.. Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
21123............ Reconstruction of chin.. Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
21125............ Augmentation, lower jaw Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
bone.
21127............ Augmentation, lower jaw Y................ ................. A2............... $1,339.00 39.8776 $1,650.97 $1,416.99
bone.
21137............ Reduction of forehead... Y................ ................. G2............... ........... 23.9765 $992.65 $992.65
21138............ Reduction of forehead... Y................ ................. G2............... ........... 39.8776 $1,650.97 $1,650.97
21139............ Reduction of forehead... Y................ ................. G2............... ........... 39.8776 $1,650.97 $1,650.97
[[Page 66952]]
21150............ Reconstruct midface, Y................ ................. G2............... ........... 39.8776 $1,650.97 $1,650.97
lefort.
21181............ Contour cranial bone Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
lesion.
21198............ Reconstr lwr jaw segment Y................ ................. G2............... ........... 39.8776 $1,650.97 $1,650.97
21199............ Reconstr lwr jaw w/ Y................ ................. G2............... ........... 39.8776 $1,650.97 $1,650.97
advance.
21206............ Reconstruct upper jaw Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
bone.
21208............ Augmentation of facial Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
bones.
21209............ Reduction of facial Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
bones.
21210............ Face bone graft......... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
21215............ Lower jaw bone graft.... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
21230............ Rib cartilage graft..... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
21235............ Ear cartilage graft..... Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
21240............ Reconstruction of jaw Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
joint.
21242............ Reconstruction of jaw Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
joint.
21243............ Reconstruction of jaw Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
joint.
21244............ Reconstruction of lower Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
jaw.
21245............ Reconstruction of jaw... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
21246............ Reconstruction of jaw... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
21248............ Reconstruction of jaw... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
21249............ Reconstruction of jaw... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
21260............ Revise eye sockets...... Y................ ................. G2............... ........... 39.8776 $1,650.97 $1,650.97
21267............ Revise eye sockets...... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
21270............ Augmentation, cheek bone Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
21275............ Revision, orbitofacial Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
bones.
21280............ Revision of eyelid...... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
21282............ Revision of eyelid...... Y................ ................. A2............... $717.00 16.3288 $676.03 $706.76
21295............ Revision of jaw muscle/ Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
bone.
21296............ Revision of jaw muscle/ Y................ ................. A2............... $333.00 23.9765 $992.65 $497.91
bone.
21310............ Treatment of nose Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
fracture.
21315............ Treatment of nose Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
fracture.
21320............ Treatment of nose Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
fracture.
21325............ Treatment of nose Y................ ................. A2............... $630.00 23.9765 $992.65 $720.66
fracture.
21330............ Treatment of nose Y................ ................. A2............... $717.00 23.9765 $992.65 $785.91
fracture.
21335............ Treatment of nose Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
fracture.
21336............ Treat nasal septal Y................ ................. A2............... $630.00 26.1592 $1,083.02 $743.26
fracture.
21337............ Treat nasal septal Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
fracture.
21338............ Treat nasoethmoid Y................ ................. A2............... $630.00 23.9765 $992.65 $720.66
fracture.
21339............ Treat nasoethmoid Y................ ................. A2............... $717.00 23.9765 $992.65 $785.91
fracture.
21340............ Treatment of nose Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
fracture.
21345............ Treat nose/jaw fracture. Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
21355............ Treat cheek bone Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
fracture.
21356............ Treat cheek bone Y................ ................. A2............... $510.00 23.9765 $992.65 $630.66
fracture.
21360............ Treat cheek bone Y................ CH............... G2............... ........... 23.9765 $992.65 $992.65
fracture.
21390............ Treat eye socket Y................ ................. G2............... ........... 39.8776 $1,650.97 $1,650.97
fracture.
21400............ Treat eye socket Y................ ................. A2............... $446.00 7.4474 $308.33 $411.58
fracture.
21401............ Treat eye socket Y................ ................. A2............... $510.00 16.3288 $676.03 $551.51
fracture.
21406............ Treat eye socket Y................ ................. G2............... ........... 39.8776 $1,650.97 $1,650.97
fracture.
21407............ Treat eye socket Y................ ................. G2............... ........... 39.8776 $1,650.97 $1,650.97
fracture.
21421............ Treat mouth roof Y................ ................. A2............... $630.00 23.9765 $992.65 $720.66
fracture.
21440............ Treat dental ridge Y................ ................. P3............... ........... 7.0605 $292.31 $292.31
fracture.
21445............ Treat dental ridge Y................ ................. A2............... $630.00 23.9765 $992.65 $720.66
fracture.
21450............ Treat lower jaw fracture Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
21451............ Treat lower jaw fracture Y................ ................. A2............... $464.15 7.4474 $308.33 $425.20
21452............ Treat lower jaw fracture Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
21453............ Treat lower jaw fracture Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
21454............ Treat lower jaw fracture Y................ ................. A2............... $717.00 23.9765 $992.65 $785.91
21461............ Treat lower jaw fracture Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
21462............ Treat lower jaw fracture Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
21465............ Treat lower jaw fracture Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
21480............ Reset dislocated jaw.... Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
21485............ Reset dislocated jaw.... Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
21490............ Repair dislocated jaw... Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
21495............ Treat hyoid bone Y................ ................. G2............... ........... 16.3288 $676.03 $676.03
fracture.
21497............ Interdental wiring...... Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
21501............ Drain neck/chest lesion. Y................ ................. A2............... $446.00 18.3197 $758.45 $524.11
21502............ Drain chest lesion...... Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
21550............ Biopsy of neck/chest.... Y................ ................. G2............... ........... 8.685 $359.57 $359.57
21555............ Remove lesion, neck/ Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
chest.
21556............ Remove lesion, neck/ Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
chest.
21557............ Remove tumor, neck/chest Y................ ................. G2............... ........... 21.1098 $873.97 $873.97
21600............ Partial removal of rib.. Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
21610............ Partial removal of rib.. Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
21685............ Hyoid myotomy & Y................ ................. G2............... ........... 7.4474 $308.33 $308.33
suspension.
21700............ Revision of neck muscle. Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
[[Page 66953]]
21720............ Revision of neck muscle. Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
21725............ Revision of neck muscle. Y................ ................. A2............... $88.46 1.4066 $58.23 $80.90
21800............ Treatment of rib Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
21805............ Treatment of rib Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
fracture.
21820............ Treat sternum fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
21920............ Biopsy soft tissue of Y................ ................. P3............... ........... 3.1763 $131.50 $131.50
back.
21925............ Biopsy soft tissue of Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
back.
21930............ Remove lesion, back or Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
flank.
21935............ Remove tumor, back...... Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
22102............ Remove part, lumbar Y................ ................. G2............... ........... 46.7724 $1,936.42 $1,936.42
vertebra.
22103............ Remove extra spine Y................ ................. G2............... ........... 46.7724 $1,936.42 $1,936.42
segment.
22305............ Treat spine process Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
22310............ Treat spine fracture.... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
22315............ Treat spine fracture.... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
22505............ Manipulation of spine... Y................ ................. A2............... $446.00 14.7658 $611.32 $487.33
22520............ Percut vertebroplasty Y................ ................. A2............... $1,339.00 29.19 $1,208.50 $1,306.38
thor.
22521............ Percut vertebroplasty Y................ ................. A2............... $1,339.00 29.19 $1,208.50 $1,306.38
lumb.
22522............ Percut vertebroplasty Y................ ................. A2............... $1,339.00 29.19 $1,208.50 $1,306.38
add 1.
22523............ Percut kyphoplasty, thor Y................ ................. G2............... ........... 79.4244 $3,288.25 $3,288.25
22524............ Percut kyphoplasty, Y................ ................. G2............... ........... 79.4244 $3,288.25 $3,288.25
lumbar.
22525............ Percut kyphoplasty, add- Y................ ................. G2............... ........... 79.4244 $3,288.25 $3,288.25
on.
22526............ Idet, single level...... Y................ CH............... G2............... ........... 29.19 $1,208.50 $1,208.50
22527............ Idet, 1 or more levels.. Y................ CH............... G2............... ........... 29.19 $1,208.50 $1,208.50
22900............ Remove abdominal wall Y................ ................. A2............... $630.00 21.1098 $873.97 $690.99
lesion.
23000............ Removal of calcium Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
deposits.
23020............ Release shoulder joint.. Y................ ................. A2............... $446.00 42.985 $1,779.62 $779.41
23030............ Drain shoulder lesion... Y................ ................. A2............... $333.00 18.3197 $758.45 $439.36
23031............ Drain shoulder bursa.... Y................ ................. A2............... $510.00 18.3197 $758.45 $572.11
23035............ Drain shoulder bone Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
lesion.
23040............ Exploratory shoulder Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
surgery.
23044............ Exploratory shoulder Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
surgery.
23065............ Biopsy shoulder tissues. Y................ ................. P3............... ........... 2.2384 $92.67 $92.67
23066............ Biopsy shoulder tissues. Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
23075............ Removal of shoulder Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
lesion.
23076............ Removal of shoulder Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
lesion.
23077............ Remove tumor of shoulder Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
23100............ Biopsy of shoulder joint Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
23101............ Shoulder joint surgery.. Y................ ................. A2............... $995.00 29.19 $1,208.50 $1,048.38
23105............ Remove shoulder joint Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
lining.
23106............ Incision of collarbone Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
joint.
23107............ Explore treat shoulder Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
joint.
23120............ Partial removal, collar Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
bone.
23125............ Removal of collar bone.. Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
23130............ Remove shoulder bone, Y................ ................. A2............... $717.00 42.985 $1,779.62 $982.66
part.
23140............ Removal of bone lesion.. Y................ ................. A2............... $630.00 21.2689 $880.55 $692.64
23145............ Removal of bone lesion.. Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
23146............ Removal of bone lesion.. Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
23150............ Removal of humerus Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
lesion.
23155............ Removal of humerus Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
lesion.
23156............ Removal of humerus Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
lesion.
23170............ Remove collar bone Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
lesion.
23172............ Remove shoulder blade Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
lesion.
23174............ Remove humerus lesion... Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
23180............ Remove collar bone Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
lesion.
23182............ Remove shoulder blade Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
lesion.
23184............ Remove humerus lesion... Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
23190............ Partial removal of Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
scapula.
23195............ Removal of head of Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
humerus.
23330............ Remove shoulder foreign Y................ ................. A2............... $333.00 8.685 $359.57 $339.64
body.
23331............ Remove shoulder foreign Y................ ................. A2............... $333.00 21.1098 $873.97 $468.24
body.
23350............ Injection for shoulder x- N................ ................. N1............... ........... ........... ........... ...........
ray.
23395............ Muscle transfer,shoulder/ Y................ ................. A2............... $717.00 42.985 $1,779.62 $982.66
arm.
23397............ Muscle transfers........ Y................ ................. A2............... $995.00 79.4244 $3,288.25 $1,568.31
23400............ Fixation of shoulder Y................ ................. A2............... $995.00 29.19 $1,208.50 $1,048.38
blade.
23405............ Incision of tendon & Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
muscle.
23406............ Incise tendon(s) & Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
muscle(s).
23410............ Repair rotator cuff, Y................ ................. A2............... $717.00 42.985 $1,779.62 $982.66
acute.
23412............ Repair rotator cuff, Y................ ................. A2............... $995.00 42.985 $1,779.62 $1,191.16
chronic.
23415............ Release of shoulder Y................ ................. A2............... $717.00 42.985 $1,779.62 $982.66
ligament.
23420............ Repair of shoulder...... Y................ ................. A2............... $995.00 42.985 $1,779.62 $1,191.16
23430............ Repair biceps tendon.... Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
23440............ Remove/transplant tendon Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
23450............ Repair shoulder capsule. Y................ ................. A2............... $717.00 79.4244 $3,288.25 $1,359.81
[[Page 66954]]
23455............ Repair shoulder capsule. Y................ ................. A2............... $995.00 79.4244 $3,288.25 $1,568.31
23460............ Repair shoulder capsule. Y................ ................. A2............... $717.00 79.4244 $3,288.25 $1,359.81
23462............ Repair shoulder capsule. Y................ ................. A2............... $995.00 42.985 $1,779.62 $1,191.16
23465............ Repair shoulder capsule. Y................ ................. A2............... $717.00 79.4244 $3,288.25 $1,359.81
23466............ Repair shoulder capsule. Y................ ................. A2............... $995.00 42.985 $1,779.62 $1,191.16
23480............ Revision of collar bone. Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
23485............ Revision of collar bone. Y................ ................. A2............... $995.00 79.4244 $3,288.25 $1,568.31
23490............ Reinforce clavicle...... Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
23491............ Reinforce shoulder bones Y................ ................. A2............... $510.00 79.4244 $3,288.25 $1,204.56
23500............ Treat clavicle fracture. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
23505............ Treat clavicle fracture. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
23515............ Treat clavicle fracture. Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
23520............ Treat clavicle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
dislocation.
23525............ Treat clavicle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
dislocation.
23530............ Treat clavicle Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
dislocation.
23532............ Treat clavicle Y................ ................. A2............... $630.00 26.1592 $1,083.02 $743.26
dislocation.
23540............ Treat clavicle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
dislocation.
23545............ Treat clavicle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
dislocation.
23550............ Treat clavicle Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
dislocation.
23552............ Treat clavicle Y................ ................. A2............... $630.00 41.1091 $1,701.96 $897.99
dislocation.
23570............ Treat shoulder blade fx. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
23575............ Treat shoulder blade fx. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
23585............ Treat scapula fracture.. Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
23600............ Treat humerus fracture.. Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
23605............ Treat humerus fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
23615............ Treat humerus fracture.. Y................ ................. A2............... $630.00 59.2233 $2,451.90 $1,085.48
23616............ Treat humerus fracture.. Y................ ................. A2............... $630.00 59.2233 $2,451.90 $1,085.48
23620............ Treat humerus fracture.. Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
23625............ Treat humerus fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
23630............ Treat humerus fracture.. Y................ ................. A2............... $717.00 59.2233 $2,451.90 $1,150.73
23650............ Treat shoulder Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
dislocation.
23655............ Treat shoulder Y................ ................. A2............... $333.00 14.7658 $611.32 $402.58
dislocation.
23660............ Treat shoulder Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
dislocation.
23665............ Treat dislocation/ Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
23670............ Treat dislocation/ Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
fracture.
23675............ Treat dislocation/ Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
23680............ Treat dislocation/ Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
fracture.
23700............ Fixation of shoulder.... Y................ ................. A2............... $333.00 14.7658 $611.32 $402.58
23800............ Fusion of shoulder joint Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
23802............ Fusion of shoulder joint Y................ ................. A2............... $995.00 42.985 $1,779.62 $1,191.16
23921............ Amputation follow-up Y................ ................. A2............... $323.28 15.0458 $622.91 $398.19
surgery.
23930............ Drainage of arm lesion.. Y................ ................. A2............... $333.00 18.3197 $758.45 $439.36
23931............ Drainage of arm bursa... Y................ ................. A2............... $446.00 18.3197 $758.45 $524.11
23935............ Drain arm/elbow bone Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
lesion.
24000............ Exploratory elbow Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
surgery.
24006............ Release elbow joint..... Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
24065............ Biopsy arm/elbow soft Y................ ................. P3............... ........... 3.0282 $125.37 $125.37
tissue.
24066............ Biopsy arm/elbow soft Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
tissue.
24075............ Remove arm/elbow lesion. Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
24076............ Remove arm/elbow lesion. Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
24077............ Remove tumor of arm/ Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
elbow.
24100............ Biopsy elbow joint Y................ ................. A2............... $333.00 21.2689 $880.55 $469.89
lining.
24101............ Explore/treat elbow Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
joint.
24102............ Remove elbow joint Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
lining.
24105............ Removal of elbow bursa.. Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
24110............ Remove humerus lesion... Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
24115............ Remove/graft bone lesion Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
24116............ Remove/graft bone lesion Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
24120............ Remove elbow lesion..... Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
24125............ Remove/graft bone lesion Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
24126............ Remove/graft bone lesion Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
24130............ Removal of head of Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
radius.
24134............ Removal of arm bone Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
lesion.
24136............ Remove radius bone Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
lesion.
24138............ Remove elbow bone lesion Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
24140............ Partial removal of arm Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
bone.
24145............ Partial removal of Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
radius.
24147............ Partial removal of elbow Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
24149............ Radical resection of Y................ ................. G2............... ........... 29.19 $1,208.50 $1,208.50
elbow.
24152............ Extensive radius surgery Y................ ................. G2............... ........... 42.985 $1,779.62 $1,779.62
24153............ Extensive radius surgery Y................ ................. G2............... ........... 79.4244 $3,288.25 $3,288.25
24155............ Removal of elbow joint.. Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
24160............ Remove elbow joint Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
implant.
[[Page 66955]]
24164............ Remove radius head Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
implant.
24200............ Removal of arm foreign Y................ ................. P3............... ........... 2.5263 $104.59 $104.59
body.
24201............ Removal of arm foreign Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
body.
24220............ Injection for elbow x- N................ ................. N1............... ........... ........... ........... ...........
ray.
24300............ Manipulate elbow w/ Y................ ................. G2............... ........... 14.7658 $611.32 $611.32
anesth.
24301............ Muscle/tendon transfer.. Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
24305............ Arm tendon lengthening.. Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
24310............ Revision of arm tendon.. Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
24320............ Repair of arm tendon.... Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
24330............ Revision of arm muscles. Y................ ................. A2............... $510.00 79.4244 $3,288.25 $1,204.56
24331............ Revision of arm muscles. Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
24332............ Tenolysis, triceps...... Y................ ................. G2............... ........... 21.2689 $880.55 $880.55
24340............ Repair of biceps tendon. Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
24341............ Repair arm tendon/muscle Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
24342............ Repair of ruptured Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
tendon.
24343............ Repr elbow lat ligmnt w/ Y................ ................. G2............... ........... 29.19 $1,208.50 $1,208.50
tiss.
24344............ Reconstruct elbow lat Y................ ................. G2............... ........... 79.4244 $3,288.25 $3,288.25
ligmnt.
24345............ Repr elbw med ligmnt w/ Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
tissu.
24346............ Reconstruct elbow med Y................ ................. G2............... ........... 42.985 $1,779.62 $1,779.62
ligmnt.
24350............ Repair of tennis elbow.. N................ CH............... D5............... ........... ........... ........... ...........
24351............ Repair of tennis elbow.. N................ CH............... D5............... ........... ........... ........... ...........
24352............ Repair of tennis elbow.. N................ CH............... D5............... ........... ........... ........... ...........
24354............ Repair of tennis elbow.. N................ CH............... D5............... ........... ........... ........... ...........
24356............ Revision of tennis elbow N................ CH............... D5............... ........... ........... ........... ...........
24357............ Repair elbow, perc...... Y................ NI............... G2............... ........... 29.19 $1,208.50 $1,208.50
24358............ Repair elbow w/deb, open Y................ NI............... G2............... ........... 29.19 $1,208.50 $1,208.50
24359............ Repair elbow deb/attch Y................ NI............... G2............... ........... 29.19 $1,208.50 $1,208.50
open.
24360............ Reconstruct elbow joint. Y................ ................. A2............... $717.00 35.904 $1,486.46 $909.37
24361............ Reconstruct elbow joint. Y................ ................. A2............... $717.00 122.2057 $5,059.44 $1,802.61
24362............ Reconstruct elbow joint. Y................ ................. A2............... $717.00 50.8876 $2,106.80 $1,064.45
24363............ Replace elbow joint..... Y................ ................. A2............... $995.00 122.2057 $5,059.44 $2,011.11
24365............ Reconstruct head of Y................ ................. A2............... $717.00 35.904 $1,486.46 $909.37
radius.
24366............ Reconstruct head of Y................ ................. A2............... $717.00 122.2057 $5,059.44 $1,802.61
radius.
24400............ Revision of humerus..... Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
24410............ Revision of humerus..... Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
24420............ Revision of humerus..... Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
24430............ Repair of humerus....... Y................ ................. A2............... $510.00 79.4244 $3,288.25 $1,204.56
24435............ Repair humerus with Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
graft.
24470............ Revision of elbow joint. Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
24495............ Decompression of forearm Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
24498............ Reinforce humerus....... Y................ ................. A2............... $510.00 79.4244 $3,288.25 $1,204.56
24500............ Treat humerus fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24505............ Treat humerus fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24515............ Treat humerus fracture.. Y................ ................. A2............... $630.00 59.2233 $2,451.90 $1,085.48
24516............ Treat humerus fracture.. Y................ ................. A2............... $630.00 59.2233 $2,451.90 $1,085.48
24530............ Treat humerus fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24535............ Treat humerus fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24538............ Treat humerus fracture.. Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
24545............ Treat humerus fracture.. Y................ ................. A2............... $630.00 59.2233 $2,451.90 $1,085.48
24546............ Treat humerus fracture.. Y................ ................. A2............... $717.00 59.2233 $2,451.90 $1,150.73
24560............ Treat humerus fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24565............ Treat humerus fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24566............ Treat humerus fracture.. Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
24575............ Treat humerus fracture.. Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
24576............ Treat humerus fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24577............ Treat humerus fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24579............ Treat humerus fracture.. Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
24582............ Treat humerus fracture.. Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
24586............ Treat elbow fracture.... Y................ ................. A2............... $630.00 59.2233 $2,451.90 $1,085.48
24587............ Treat elbow fracture.... Y................ ................. A2............... $717.00 59.2233 $2,451.90 $1,150.73
24600............ Treat elbow dislocation. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24605............ Treat elbow dislocation. Y................ ................. A2............... $446.00 14.7658 $611.32 $487.33
24615............ Treat elbow dislocation. Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
24620............ Treat elbow fracture.... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24635............ Treat elbow fracture.... Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
24640............ Treat elbow dislocation. Y................ CH............... P3............... ........... 1.3823 $57.23 $57.23
24650............ Treat radius fracture... Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
24655............ Treat radius fracture... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24665............ Treat radius fracture... Y................ ................. A2............... $630.00 41.1091 $1,701.96 $897.99
24666............ Treat radius fracture... Y................ ................. A2............... $630.00 59.2233 $2,451.90 $1,085.48
24670............ Treat ulnar fracture.... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24675............ Treat ulnar fracture.... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
24685............ Treat ulnar fracture.... Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
[[Page 66956]]
24800............ Fusion of elbow joint... Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
24802............ Fusion/graft of elbow Y................ ................. A2............... $717.00 42.985 $1,779.62 $982.66
joint.
24925............ Amputation follow-up Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
surgery.
25000............ Incision of tendon Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
sheath.
25001............ Incise flexor carpi Y................ ................. G2............... ........... 21.2689 $880.55 $880.55
radialis.
25020............ Decompress forearm 1 Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
space.
25023............ Decompress forearm 1 Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
space.
25024............ Decompress forearm 2 Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
spaces.
25025............ Decompress forearm 2 Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
spaces.
25028............ Drainage of forearm Y................ ................. A2............... $333.00 21.2689 $880.55 $469.89
lesion.
25031............ Drainage of forearm Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
bursa.
25035............ Treat forearm bone Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
lesion.
25040............ Explore/treat wrist Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
joint.
25065............ Biopsy forearm soft Y................ ................. P3............... ........... 3.1023 $128.44 $128.44
tissues.
25066............ Biopsy forearm soft Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
tissues.
25075............ Removal forearm lesion Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
subcu.
25076............ Removal forearm lesion Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
deep.
25077............ Remove tumor, forearm/ Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
wrist.
25085............ Incision of wrist Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
capsule.
25100............ Biopsy of wrist joint... Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
25101............ Explore/treat wrist Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
joint.
25105............ Remove wrist joint Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
lining.
25107............ Remove wrist joint Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
cartilage.
25109............ Excise tendon forearm/ Y................ ................. G2............... ........... 21.2689 $880.55 $880.55
wrist.
25110............ Remove wrist tendon Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
lesion.
25111............ Remove wrist tendon Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
lesion.
25112............ Reremove wrist tendon Y................ ................. A2............... $630.00 16.4637 $681.61 $642.90
lesion.
25115............ Remove wrist/forearm Y................ ................. A2............... $630.00 21.2689 $880.55 $692.64
lesion.
25116............ Remove wrist/forearm Y................ ................. A2............... $630.00 21.2689 $880.55 $692.64
lesion.
25118............ Excise wrist tendon Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
sheath.
25119............ Partial removal of ulna. Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
25120............ Removal of forearm Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
lesion.
25125............ Remove/graft forearm Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
lesion.
25126............ Remove/graft forearm Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
lesion.
25130............ Removal of wrist lesion. Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
25135............ Remove & graft wrist Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
lesion.
25136............ Remove & graft wrist Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
lesion.
25145............ Remove forearm bone Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
lesion.
25150............ Partial removal of ulna. Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
25151............ Partial removal of Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
radius.
25210............ Removal of wrist bone... Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
25215............ Removal of wrist bones.. Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
25230............ Partial removal of Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
radius.
25240............ Partial removal of ulna. Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
25246............ Injection for wrist x- N................ ................. N1............... ........... ........... ........... ...........
ray.
25248............ Remove forearm foreign Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
body.
25250............ Removal of wrist Y................ ................. A2............... $333.00 29.19 $1,208.50 $551.88
prosthesis.
25251............ Removal of wrist Y................ ................. A2............... $333.00 29.19 $1,208.50 $551.88
prosthesis.
25259............ Manipulate wrist w/ Y................ ................. G2............... ........... 1.7682 $73.21 $73.21
anesthes.
25260............ Repair forearm tendon/ Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
muscle.
25263............ Repair forearm tendon/ Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
muscle.
25265............ Repair forearm tendon/ Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
muscle.
25270............ Repair forearm tendon/ Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
muscle.
25272............ Repair forearm tendon/ Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
muscle.
25274............ Repair forearm tendon/ Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
muscle.
25275............ Repair forearm tendon Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
sheath.
25280............ Revise wrist/forearm Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
tendon.
25290............ Incise wrist/forearm Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
tendon.
25295............ Release wrist/forearm Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
tendon.
25300............ Fusion of tendons at Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
wrist.
25301............ Fusion of tendons at Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
wrist.
25310............ Transplant forearm Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
tendon.
25312............ Transplant forearm Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
tendon.
25315............ Revise palsy hand Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
tendon(s).
25316............ Revise palsy hand Y................ ................. A2............... $510.00 79.4244 $3,288.25 $1,204.56
tendon(s).
25320............ Repair/revise wrist Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
joint.
25332............ Revise wrist joint...... Y................ ................. A2............... $717.00 35.904 $1,486.46 $909.37
25335............ Realignment of hand..... Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
25337............ Reconstruct ulna/ Y................ ................. A2............... $717.00 42.985 $1,779.62 $982.66
radioulnar.
25350............ Revision of radius...... Y................ ................. A2............... $510.00 79.4244 $3,288.25 $1,204.56
25355............ Revision of radius...... Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
25360............ Revision of ulna........ Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
25365............ Revise radius & ulna.... Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
[[Page 66957]]
25370............ Revise radius or ulna... Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
25375............ Revise radius & ulna.... Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
25390............ Shorten radius or ulna.. Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
25391............ Lengthen radius or ulna. Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
25392............ Shorten radius & ulna... Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
25393............ Lengthen radius & ulna.. Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
25394............ Repair carpal bone, Y................ ................. G2............... ........... 16.4637 $681.61 $681.61
shorten.
25400............ Repair radius or ulna... Y................ ................. A2............... $510.00 79.4244 $3,288.25 $1,204.56
25405............ Repair/graft radius or Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
ulna.
25415............ Repair radius & ulna.... Y................ ................. A2............... $510.00 79.4244 $3,288.25 $1,204.56
25420............ Repair/graft radius & Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
ulna.
25425............ Repair/graft radius or Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
ulna.
25426............ Repair/graft radius & Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
ulna.
25430............ Vasc graft into carpal Y................ ................. G2............... ........... 26.3105 $1,089.28 $1,089.28
bone.
25431............ Repair nonunion carpal Y................ ................. G2............... ........... 26.3105 $1,089.28 $1,089.28
bone.
25440............ Repair/graft wrist bone. Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
25441............ Reconstruct wrist joint. Y................ ................. A2............... $717.00 122.2057 $5,059.44 $1,802.61
25442............ Reconstruct wrist joint. Y................ ................. A2............... $717.00 122.2057 $5,059.44 $1,802.61
25443............ Reconstruct wrist joint. Y................ ................. A2............... $717.00 50.8876 $2,106.80 $1,064.45
25444............ Reconstruct wrist joint. Y................ ................. A2............... $717.00 50.8876 $2,106.80 $1,064.45
25445............ Reconstruct wrist joint. Y................ ................. A2............... $717.00 50.8876 $2,106.80 $1,064.45
25446............ Wrist replacement....... Y................ ................. A2............... $995.00 122.2057 $5,059.44 $2,011.11
25447............ Repair wrist joint(s)... Y................ ................. A2............... $717.00 35.904 $1,486.46 $909.37
25449............ Remove wrist joint Y................ ................. A2............... $717.00 35.904 $1,486.46 $909.37
implant.
25450............ Revision of wrist joint. Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
25455............ Revision of wrist joint. Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
25490............ Reinforce radius........ Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
25491............ Reinforce ulna.......... Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
25492............ Reinforce radius and Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
ulna.
25500............ Treat fracture of radius Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
25505............ Treat fracture of radius Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
25515............ Treat fracture of radius Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
25520............ Treat fracture of radius Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
25525............ Treat fracture of radius Y................ ................. A2............... $630.00 41.1091 $1,701.96 $897.99
25526............ Treat fracture of radius Y................ ................. A2............... $717.00 41.1091 $1,701.96 $963.24
25530............ Treat fracture of ulna.. Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
25535............ Treat fracture of ulna.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
25545............ Treat fracture of ulna.. Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
25560............ Treat fracture radius & Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
ulna.
25565............ Treat fracture radius & Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
ulna.
25574............ Treat fracture radius & Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
ulna.
25575............ Treat fracture radius/ Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
ulna.
25600............ Treat fracture radius/ Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
ulna.
25605............ Treat fracture radius/ Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
ulna.
25606............ Treat fx distal radial.. Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
25607............ Treat fx rad extra- Y................ ................. A2............... $717.00 59.2233 $2,451.90 $1,150.73
articul.
25608............ Treat fx rad intra- Y................ ................. A2............... $717.00 59.2233 $2,451.90 $1,150.73
articul.
25609............ Treat fx radial 3+ frag. Y................ ................. A2............... $717.00 59.2233 $2,451.90 $1,150.73
25622............ Treat wrist bone Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
fracture.
25624............ Treat wrist bone Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
25628............ Treat wrist bone Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
fracture.
25630............ Treat wrist bone Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
fracture.
25635............ Treat wrist bone Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
25645............ Treat wrist bone Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
fracture.
25650............ Treat wrist bone Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
fracture.
25651............ Pin ulnar styloid Y................ ................. G2............... ........... 26.1592 $1,083.02 $1,083.02
fracture.
25652............ Treat fracture ulnar Y................ ................. G2............... ........... 41.1091 $1,701.96 $1,701.96
styloid.
25660............ Treat wrist dislocation. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
25670............ Treat wrist dislocation. Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
25671............ Pin radioulnar Y................ ................. A2............... $333.00 26.1592 $1,083.02 $520.51
dislocation.
25675............ Treat wrist dislocation. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
25676............ Treat wrist dislocation. Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
25680............ Treat wrist fracture.... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
25685............ Treat wrist fracture.... Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
25690............ Treat wrist dislocation. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
25695............ Treat wrist dislocation. Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
25800............ Fusion of wrist joint... Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
25805............ Fusion/graft of wrist Y................ ................. A2............... $717.00 42.985 $1,779.62 $982.66
joint.
25810............ Fusion/graft of wrist Y................ ................. A2............... $717.00 79.4244 $3,288.25 $1,359.81
joint.
25820............ Fusion of hand bones.... Y................ ................. A2............... $630.00 16.4637 $681.61 $642.90
25825............ Fuse hand bones with Y................ ................. A2............... $717.00 79.4244 $3,288.25 $1,359.81
graft.
25830............ Fusion, radioulnar jnt/ Y................ ................. A2............... $717.00 79.4244 $3,288.25 $1,359.81
ulna.
25907............ Amputation follow-up Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
surgery.
[[Page 66958]]
25922............ Amputate hand at wrist.. Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
25929............ Amputation follow-up Y................ ................. A2............... $510.00 15.0458 $622.91 $538.23
surgery.
25931............ Amputation follow-up Y................ CH............... G2............... ........... 21.2689 $880.55 $880.55
surgery.
26010............ Drainage of finger Y................ ................. P2............... ........... 1.4066 $58.23 $58.23
abscess.
26011............ Drainage of finger Y................ ................. A2............... $333.00 11.5594 $478.57 $369.39
abscess.
26020............ Drain hand tendon sheath Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
26025............ Drainage of palm bursa.. Y................ ................. A2............... $333.00 16.4637 $681.61 $420.15
26030............ Drainage of palm Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
bursa(s).
26034............ Treat hand bone lesion.. Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
26035............ Decompress fingers/hand. Y................ ................. G2............... ........... 16.4637 $681.61 $681.61
26040............ Release palm contracture Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26045............ Release palm contracture Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26055............ Incise finger tendon Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
sheath.
26060............ Incision of finger Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
tendon.
26070............ Explore/treat hand joint Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
26075............ Explore/treat finger Y................ ................. A2............... $630.00 16.4637 $681.61 $642.90
joint.
26080............ Explore/treat finger Y................ ................. A2............... $630.00 16.4637 $681.61 $642.90
joint.
26100............ Biopsy hand joint lining Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
26105............ Biopsy finger joint Y................ ................. A2............... $333.00 16.4637 $681.61 $420.15
lining.
26110............ Biopsy finger joint Y................ ................. A2............... $333.00 16.4637 $681.61 $420.15
lining.
26115............ Removal hand lesion Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
subcut.
26116............ Removal hand lesion, Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
deep.
26117............ Remove tumor, hand/ Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
finger.
26121............ Release palm contracture Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26123............ Release palm contracture Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26125............ Release palm contracture Y................ ................. A2............... $630.00 16.4637 $681.61 $642.90
26130............ Remove wrist joint Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
lining.
26135............ Revise finger joint, Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
each.
26140............ Revise finger joint, Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
each.
26145............ Tendon excision, palm/ Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
finger.
26160............ Remove tendon sheath Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
lesion.
26170............ Removal of palm tendon, Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
each.
26180............ Removal of finger tendon Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
26185............ Remove finger bone...... Y................ ................. A2............... $630.00 16.4637 $681.61 $642.90
26200............ Remove hand bone lesion. Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
26205............ Remove/graft bone lesion Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26210............ Removal of finger lesion Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
26215............ Remove/graft finger Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
lesion.
26230............ Partial removal of hand Y................ ................. A2............... $992.95 16.4637 $681.61 $915.12
bone.
26235............ Partial removal, finger Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
bone.
26236............ Partial removal, finger Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
bone.
26250............ Extensive hand surgery.. Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
26255............ Extensive hand surgery.. Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26260............ Extensive finger surgery Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
26261............ Extensive finger surgery Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
26262............ Partial removal of Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
finger.
26320............ Removal of implant from Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
hand.
26340............ Manipulate finger w/ Y................ ................. G2............... ........... 1.7682 $73.21 $73.21
anesth.
26350............ Repair finger/hand Y................ ................. A2............... $333.00 26.3105 $1,089.28 $522.07
tendon.
26352............ Repair/graft hand tendon Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26356............ Repair finger/hand Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
tendon.
26357............ Repair finger/hand Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
tendon.
26358............ Repair/graft hand tendon Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26370............ Repair finger/hand Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
tendon.
26372............ Repair/graft hand tendon Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26373............ Repair finger/hand Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
tendon.
26390............ Revise hand/finger Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
tendon.
26392............ Repair/graft hand tendon Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26410............ Repair hand tendon...... Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
26412............ Repair/graft hand tendon Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26415............ Excision, hand/finger Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
tendon.
26416............ Graft hand or finger Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
tendon.
26418............ Repair finger tendon.... Y................ ................. A2............... $630.00 16.4637 $681.61 $642.90
26420............ Repair/graft finger Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
tendon.
26426............ Repair finger/hand Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
tendon.
26428............ Repair/graft finger Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
tendon.
26432............ Repair finger tendon.... Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
26433............ Repair finger tendon.... Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
26434............ Repair/graft finger Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
tendon.
26437............ Realignment of tendons.. Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
26440............ Release palm/finger Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
tendon.
26442............ Release palm & finger Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
tendon.
26445............ Release hand/finger Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
tendon.
[[Page 66959]]
26449............ Release forearm/hand Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
tendon.
26450............ Incision of palm tendon. Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
26455............ Incision of finger Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
tendon.
26460............ Incise hand/finger Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
tendon.
26471............ Fusion of finger tendons Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
26474............ Fusion of finger tendons Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
26476............ Tendon lengthening...... Y................ ................. A2............... $333.00 16.4637 $681.61 $420.15
26477............ Tendon shortening....... Y................ ................. A2............... $333.00 16.4637 $681.61 $420.15
26478............ Lengthening of hand Y................ ................. A2............... $333.00 16.4637 $681.61 $420.15
tendon.
26479............ Shortening of hand Y................ ................. A2............... $333.00 16.4637 $681.61 $420.15
tendon.
26480............ Transplant hand tendon.. Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26483............ Transplant/graft hand Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
tendon.
26485............ Transplant palm tendon.. Y................ ................. A2............... $446.00 26.3105 $1,089.28 $606.82
26489............ Transplant/graft palm Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
tendon.
26490............ Revise thumb tendon..... Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26492............ Tendon transfer with Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
graft.
26494............ Hand tendon/muscle Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
transfer.
26496............ Revise thumb tendon..... Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26497............ Finger tendon transfer.. Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26498............ Finger tendon transfer.. Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26499............ Revision of finger...... Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26500............ Hand tendon Y................ ................. A2............... $630.00 16.4637 $681.61 $642.90
reconstruction.
26502............ Hand tendon Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
reconstruction.
26508............ Release thumb Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
contracture.
26510............ Thumb tendon transfer... Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26516............ Fusion of knuckle joint. Y................ ................. A2............... $333.00 26.3105 $1,089.28 $522.07
26517............ Fusion of knuckle joints Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26518............ Fusion of knuckle joints Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26520............ Release knuckle Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
contracture.
26525............ Release finger Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
contracture.
26530............ Revise knuckle joint.... Y................ ................. A2............... $510.00 35.904 $1,486.46 $754.12
26531............ Revise knuckle with Y................ ................. A2............... $995.00 50.8876 $2,106.80 $1,272.95
implant.
26535............ Revise finger joint..... Y................ ................. A2............... $717.00 35.904 $1,486.46 $909.37
26536............ Revise/implant finger Y................ ................. A2............... $717.00 50.8876 $2,106.80 $1,064.45
joint.
26540............ Repair hand joint....... Y................ ................. A2............... $630.00 16.4637 $681.61 $642.90
26541............ Repair hand joint with Y................ ................. A2............... $995.00 26.3105 $1,089.28 $1,018.57
graft.
26542............ Repair hand joint with Y................ ................. A2............... $630.00 16.4637 $681.61 $642.90
graft.
26545............ Reconstruct finger joint Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26546............ Repair nonunion hand.... Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26548............ Reconstruct finger joint Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26550............ Construct thumb Y................ ................. A2............... $446.00 26.3105 $1,089.28 $606.82
replacement.
26555............ Positional change of Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
finger.
26560............ Repair of web finger.... Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
26561............ Repair of web finger.... Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26562............ Repair of web finger.... Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26565............ Correct metacarpal flaw. Y................ ................. A2............... $717.00 26.3105 $1,089.28 $810.07
26567............ Correct finger deformity Y................ ................. A2............... $717.00 26.3105 $1,089.28 $810.07
26568............ Lengthen metacarpal/ Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
finger.
26580............ Repair hand deformity... Y................ ................. A2............... $717.00 16.4637 $681.61 $708.15
26587............ Reconstruct extra finger Y................ ................. A2............... $717.00 16.4637 $681.61 $708.15
26590............ Repair finger deformity. Y................ ................. A2............... $717.00 16.4637 $681.61 $708.15
26591............ Repair muscles of hand.. Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26593............ Release muscles of hand. Y................ ................. A2............... $510.00 16.4637 $681.61 $552.90
26596............ Excision constricting Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
tissue.
26600............ Treat metacarpal Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
fracture.
26605............ Treat metacarpal Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
26607............ Treat metacarpal Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
26608............ Treat metacarpal Y................ ................. A2............... $630.00 26.1592 $1,083.02 $743.26
fracture.
26615............ Treat metacarpal Y................ ................. A2............... $630.00 41.1091 $1,701.96 $897.99
fracture.
26641............ Treat thumb dislocation. Y................ CH............... P2............... ........... 1.7682 $73.21 $73.21
26645............ Treat thumb fracture.... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
26650............ Treat thumb fracture.... Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
26665............ Treat thumb fracture.... Y................ ................. A2............... $630.00 41.1091 $1,701.96 $897.99
26670............ Treat hand dislocation.. Y................ CH............... P2............... ........... 1.7682 $73.21 $73.21
26675............ Treat hand dislocation.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
26676............ Pin hand dislocation.... Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
26685............ Treat hand dislocation.. Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
26686............ Treat hand dislocation.. Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
26700............ Treat knuckle Y................ CH............... P2............... ........... 1.7682 $73.21 $73.21
dislocation.
26705............ Treat knuckle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
dislocation.
26706............ Pin knuckle dislocation. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
26715............ Treat knuckle Y................ ................. A2............... $630.00 26.1592 $1,083.02 $743.26
dislocation.
26720............ Treat finger fracture, Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
each.
[[Page 66960]]
26725............ Treat finger fracture, Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
each.
26727............ Treat finger fracture, Y................ ................. A2............... $995.00 26.1592 $1,083.02 $1,017.01
each.
26735............ Treat finger fracture, Y................ ................. A2............... $630.00 26.1592 $1,083.02 $743.26
each.
26740............ Treat finger fracture, Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
each.
26742............ Treat finger fracture, Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
each.
26746............ Treat finger fracture, Y................ ................. A2............... $717.00 26.1592 $1,083.02 $808.51
each.
26750............ Treat finger fracture, Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
each.
26755............ Treat finger fracture, Y................ ................. G2............... ........... 1.7682 $73.21 $73.21
each.
26756............ Pin finger fracture, Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
each.
26765............ Treat finger fracture, Y................ ................. A2............... $630.00 26.1592 $1,083.02 $743.26
each.
26770............ Treat finger dislocation Y................ ................. G2............... ........... 1.7682 $73.21 $73.21
26775............ Treat finger dislocation Y................ CH............... P3............... ........... 4.032 $166.93 $166.93
26776............ Pin finger dislocation.. Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
26785............ Treat finger dislocation Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
26820............ Thumb fusion with graft. Y................ ................. A2............... $717.00 26.3105 $1,089.28 $810.07
26841............ Fusion of thumb......... Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26842............ Thumb fusion with graft. Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26843............ Fusion of hand joint.... Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26844............ Fusion/graft of hand Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
joint.
26850............ Fusion of knuckle....... Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
26852............ Fusion of knuckle with Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
graft.
26860............ Fusion of finger joint.. Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26861............ Fusion of finger jnt, Y................ ................. A2............... $446.00 26.3105 $1,089.28 $606.82
add-on.
26862............ Fusion/graft of finger Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
joint.
26863............ Fuse/graft added joint.. Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26910............ Amputate metacarpal bone Y................ ................. A2............... $510.00 26.3105 $1,089.28 $654.82
26951............ Amputation of finger/ Y................ ................. A2............... $446.00 16.4637 $681.61 $504.90
thumb.
26952............ Amputation of finger/ Y................ ................. A2............... $630.00 16.4637 $681.61 $642.90
thumb.
26990............ Drainage of pelvis Y................ ................. A2............... $333.00 21.2689 $880.55 $469.89
lesion.
26991............ Drainage of pelvis bursa Y................ ................. A2............... $333.00 21.2689 $880.55 $469.89
27000............ Incision of hip tendon.. Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
27001............ Incision of hip tendon.. Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
27003............ Incision of hip tendon.. Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
27033............ Exploration of hip joint Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
27035............ Denervation of hip joint Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
27040............ Biopsy of soft tissues.. Y................ ................. A2............... $333.00 8.685 $359.57 $339.64
27041............ Biopsy of soft tissues.. Y................ ................. A2............... $418.49 8.685 $359.57 $403.76
27047............ Remove hip/pelvis lesion Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
27048............ Remove hip/pelvis lesion Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
27049............ Remove tumor, hip/pelvis Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
27050............ Biopsy of sacroiliac Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
joint.
27052............ Biopsy of hip joint..... Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
27060............ Removal of ischial bursa Y................ ................. A2............... $717.00 21.2689 $880.55 $757.89
27062............ Remove femur lesion/ Y................ ................. A2............... $717.00 21.2689 $880.55 $757.89
bursa.
27065............ Removal of hip bone Y................ ................. A2............... $717.00 21.2689 $880.55 $757.89
lesion.
27066............ Removal of hip bone Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
lesion.
27067............ Remove/graft hip bone Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
lesion.
27080............ Removal of tail bone.... Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
27086............ Remove hip foreign body. Y................ ................. A2............... $333.00 8.685 $359.57 $339.64
27087............ Remove hip foreign body. Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
27093............ Injection for hip x-ray. N................ ................. N1............... ........... ........... ........... ...........
27095............ Injection for hip x-ray. N................ ................. N1............... ........... ........... ........... ...........
27097............ Revision of hip tendon.. Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
27098............ Transfer tendon to Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
pelvis.
27100............ Transfer of abdominal Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
muscle.
27105............ Transfer of spinal Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
muscle.
27110............ Transfer of iliopsoas Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
muscle.
27111............ Transfer of iliopsoas Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
muscle.
27193............ Treat pelvic ring Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27194............ Treat pelvic ring Y................ ................. A2............... $446.00 14.7658 $611.32 $487.33
fracture.
27200............ Treat tail bone fracture Y................ CH............... P3............... ........... 1.7693 $73.25 $73.25
27202............ Treat tail bone fracture Y................ ................. A2............... $446.00 41.1091 $1,701.96 $759.99
27220............ Treat hip socket Y................ ................. G2............... ........... 1.7682 $73.21 $73.21
fracture.
27230............ Treat thigh fracture.... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27238............ Treat thigh fracture.... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27246............ Treat thigh fracture.... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27250............ Treat hip dislocation... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27252............ Treat hip dislocation... Y................ ................. A2............... $446.00 14.7658 $611.32 $487.33
27256............ Treat hip dislocation... Y................ ................. G2............... ........... 1.7682 $73.21 $73.21
27257............ Treat hip dislocation... Y................ ................. A2............... $510.00 14.7658 $611.32 $535.33
27265............ Treat hip dislocation... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27266............ Treat hip dislocation... Y................ ................. A2............... $446.00 14.7658 $611.32 $487.33
27267............ Cltx thigh fx........... Y................ NI............... G2............... ........... 1.7682 $73.21 $73.21
[[Page 66961]]
27275............ Manipulation of hip Y................ ................. A2............... $446.00 14.7658 $611.32 $487.33
joint.
27301............ Drain thigh/knee lesion. Y................ ................. A2............... $510.00 18.3197 $758.45 $572.11
27305............ Incise thigh tendon & Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
fascia.
27306............ Incision of thigh tendon Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
27307............ Incision of thigh Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
tendons.
27310............ Exploration of knee Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
joint.
27323............ Biopsy, thigh soft Y................ ................. A2............... $333.00 8.685 $359.57 $339.64
tissues.
27324............ Biopsy, thigh soft Y................ ................. A2............... $333.00 21.1098 $873.97 $468.24
tissues.
27325............ Neurectomy, hamstring... Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
27326............ Neurectomy, popliteal... Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
27327............ Removal of thigh lesion. Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
27328............ Removal of thigh lesion. Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
27329............ Remove tumor, thigh/knee Y................ ................. A2............... $630.00 21.1098 $873.97 $690.99
27330............ Biopsy, knee joint Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
lining.
27331............ Explore/treat knee joint Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
27332............ Removal of knee Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
cartilage.
27333............ Removal of knee Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
cartilage.
27334............ Remove knee joint lining Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
27335............ Remove knee joint lining Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
27340............ Removal of kneecap bursa Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
27345............ Removal of knee cyst.... Y................ ................. A2............... $630.00 21.2689 $880.55 $692.64
27347............ Remove knee cyst........ Y................ ................. A2............... $630.00 21.2689 $880.55 $692.64
27350............ Removal of kneecap...... Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
27355............ Remove femur lesion..... Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
27356............ Remove femur lesion/ Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
graft.
27357............ Remove femur lesion/ Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
graft.
27358............ Remove femur lesion/ Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
fixation.
27360............ Partial removal, leg Y................ ................. A2............... $717.00 29.19 $1,208.50 $839.88
bone(s).
27370............ Injection for knee x-ray N................ ................. N1............... ........... ........... ........... ...........
27372............ Removal of foreign body. Y................ ................. A2............... $995.00 21.1098 $873.97 $964.74
27380............ Repair of kneecap tendon Y................ ................. A2............... $333.00 21.2689 $880.55 $469.89
27381............ Repair/graft kneecap Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
tendon.
27385............ Repair of thigh muscle.. Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
27386............ Repair/graft of thigh Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
muscle.
27390............ Incision of thigh tendon Y................ ................. A2............... $333.00 21.2689 $880.55 $469.89
27391............ Incision of thigh Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
tendons.
27392............ Incision of thigh Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
tendons.
27393............ Lengthening of thigh Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
tendon.
27394............ Lengthening of thigh Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
tendons.
27395............ Lengthening of thigh Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
tendons.
27396............ Transplant of thigh Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
tendon.
27397............ Transplants of thigh Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
tendons.
27400............ Revise thigh muscles/ Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
tendons.
27403............ Repair of knee cartilage Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
27405............ Repair of knee ligament. Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
27407............ Repair of knee ligament. Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
27409............ Repair of knee ligaments Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
27416............ Osteochondral knee Y................ NI............... G2............... ........... 42.985 $1,779.62 $1,779.62
autograft.
27418............ Repair degenerated Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
kneecap.
27420............ Revision of unstable Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
kneecap.
27422............ Revision of unstable Y................ ................. A2............... $995.00 42.985 $1,779.62 $1,191.16
kneecap.
27424............ Revision/removal of Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
kneecap.
27425............ Lat retinacular release Y................ ................. A2............... $995.00 29.19 $1,208.50 $1,048.38
open.
27427............ Reconstruction, knee.... Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
27428............ Reconstruction, knee.... Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
27429............ Reconstruction, knee.... Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
27430............ Revision of thigh Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
muscles.
27435............ Incision of knee joint.. Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
27437............ Revise kneecap.......... Y................ ................. A2............... $630.00 35.904 $1,486.46 $844.12
27438............ Revise kneecap with Y................ ................. A2............... $717.00 50.8876 $2,106.80 $1,064.45
implant.
27440............ Revision of knee joint.. Y................ ................. G2............... ........... 35.904 $1,486.46 $1,486.46
27441............ Revision of knee joint.. Y................ ................. A2............... $717.00 35.904 $1,486.46 $909.37
27442............ Revision of knee joint.. Y................ ................. A2............... $717.00 35.904 $1,486.46 $909.37
27443............ Revision of knee joint.. Y................ ................. A2............... $717.00 35.904 $1,486.46 $909.37
27446............ Revision of knee joint.. Y................ ................. G2............... ........... 274.6715 $11,371.67 $11,371.67
27496............ Decompression of thigh/ Y................ ................. A2............... $717.00 21.2689 $880.55 $757.89
knee.
27497............ Decompression of thigh/ Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
knee.
27498............ Decompression of thigh/ Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
knee.
27499............ Decompression of thigh/ Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
knee.
27500............ Treatment of thigh Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27501............ Treatment of thigh Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27502............ Treatment of thigh Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27503............ Treatment of thigh Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
[[Page 66962]]
27508............ Treatment of thigh Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27509............ Treatment of thigh Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
fracture.
27510............ Treatment of thigh Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27516............ Treat thigh fx growth Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
plate.
27517............ Treat thigh fx growth Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
plate.
27520............ Treat kneecap fracture.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27530............ Treat knee fracture..... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27532............ Treat knee fracture..... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27538............ Treat knee fracture(s).. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27550............ Treat knee dislocation.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27552............ Treat knee dislocation.. Y................ ................. A2............... $333.00 14.7658 $611.32 $402.58
27560............ Treat kneecap Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
dislocation.
27562............ Treat kneecap Y................ ................. A2............... $333.00 14.7658 $611.32 $402.58
dislocation.
27566............ Treat kneecap Y................ ................. A2............... $446.00 41.1091 $1,701.96 $759.99
dislocation.
27570............ Fixation of knee joint.. Y................ ................. A2............... $333.00 14.7658 $611.32 $402.58
27594............ Amputation follow-up Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
surgery.
27600............ Decompression of lower Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
leg.
27601............ Decompression of lower Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
leg.
27602............ Decompression of lower Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
leg.
27603............ Drain lower leg lesion.. Y................ ................. A2............... $446.00 18.3197 $758.45 $524.11
27604............ Drain lower leg bursa... Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
27605............ Incision of achilles Y................ ................. A2............... $333.00 20.8284 $862.32 $465.33
tendon.
27606............ Incision of achilles Y................ ................. A2............... $333.00 21.2689 $880.55 $469.89
tendon.
27607............ Treat lower leg bone Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
lesion.
27610............ Explore/treat ankle Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
joint.
27612............ Exploration of ankle Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
joint.
27613............ Biopsy lower leg soft Y................ ................. P3............... ........... 2.9376 $121.62 $121.62
tissue.
27614............ Biopsy lower leg soft Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
tissue.
27615............ Remove tumor, lower leg. Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
27618............ Remove lower leg lesion. Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
27619............ Remove lower leg lesion. Y................ ................. A2............... $510.00 21.1098 $873.97 $600.99
27620............ Explore/treat ankle Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
joint.
27625............ Remove ankle joint Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
lining.
27626............ Remove ankle joint Y................ ................. A2............... $630.00 29.19 $1,208.50 $774.63
lining.
27630............ Removal of tendon lesion Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
27635............ Remove lower leg bone Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
lesion.
27637............ Remove/graft leg bone Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
lesion.
27638............ Remove/graft leg bone Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
lesion.
27640............ Partial removal of tibia Y................ ................. A2............... $446.00 42.985 $1,779.62 $779.41
27641............ Partial removal of Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
fibula.
27647............ Extensive ankle/heel Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
surgery.
27648............ Injection for ankle x- N................ ................. N1............... ........... ........... ........... ...........
ray.
27650............ Repair achilles tendon.. Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
27652............ Repair/graft achilles Y................ ................. A2............... $510.00 79.4244 $3,288.25 $1,204.56
tendon.
27654............ Repair of achilles Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
tendon.
27656............ Repair leg fascia defect Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
27658............ Repair of leg tendon, Y................ ................. A2............... $333.00 21.2689 $880.55 $469.89
each.
27659............ Repair of leg tendon, Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
each.
27664............ Repair of leg tendon, Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
each.
27665............ Repair of leg tendon, Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
each.
27675............ Repair lower leg tendons Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
27676............ Repair lower leg tendons Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
27680............ Release of lower leg Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
tendon.
27681............ Release of lower leg Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
tendons.
27685............ Revision of lower leg Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
tendon.
27686............ Revise lower leg tendons Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
27687............ Revision of calf tendon. Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
27690............ Revise lower leg tendon. Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
27691............ Revise lower leg tendon. Y................ ................. A2............... $630.00 42.985 $1,779.62 $917.41
27692............ Revise additional leg Y................ ................. A2............... $510.00 42.985 $1,779.62 $827.41
tendon.
27695............ Repair of ankle ligament Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
27696............ Repair of ankle Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
ligaments.
27698............ Repair of ankle ligament Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
27700............ Revision of ankle joint. Y................ ................. A2............... $717.00 35.904 $1,486.46 $909.37
27704............ Removal of ankle implant Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
27705............ Incision of tibia....... Y................ ................. A2............... $446.00 42.985 $1,779.62 $779.41
27707............ Incision of fibula...... Y................ ................. A2............... $446.00 21.2689 $880.55 $554.64
27709............ Incision of tibia & Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
fibula.
27726............ Repair fibula nonunion.. Y................ NI............... G2............... ........... 26.1592 $1,083.02 $1,083.02
27730............ Repair of tibia Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
epiphysis.
27732............ Repair of fibula Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
epiphysis.
27734............ Repair lower leg Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
epiphyses.
27740............ Repair of leg epiphyses. Y................ ................. A2............... $446.00 29.19 $1,208.50 $636.63
[[Page 66963]]
27742............ Repair of leg epiphyses. Y................ ................. A2............... $446.00 42.985 $1,779.62 $779.41
27745............ Reinforce tibia......... Y................ ................. A2............... $510.00 79.4244 $3,288.25 $1,204.56
27750............ Treatment of tibia Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27752............ Treatment of tibia Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27756............ Treatment of tibia Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
fracture.
27758............ Treatment of tibia Y................ ................. A2............... $630.00 41.1091 $1,701.96 $897.99
fracture.
27759............ Treatment of tibia Y................ ................. A2............... $630.00 59.2233 $2,451.90 $1,085.48
fracture.
27760............ Cltx medial ankle fx.... Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27762............ Cltx med ankle fx w/mnpj Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27766............ Optx medial ankle fx.... Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
27767............ Cltx post ankle fx...... Y................ NI............... G2............... ........... 1.7682 $73.21 $73.21
27768............ Cltx post ankle fx w/ Y................ NI............... G2............... ........... 1.7682 $73.21 $73.21
mnpj.
27769............ Optx post ankle fx...... Y................ NI............... G2............... ........... 41.1091 $1,701.96 $1,701.96
27780............ Treatment of fibula Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27781............ Treatment of fibula Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27784............ Treatment of fibula Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
fracture.
27786............ Treatment of ankle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27788............ Treatment of ankle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27792............ Treatment of ankle Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
fracture.
27808............ Treatment of ankle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27810............ Treatment of ankle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27814............ Treatment of ankle Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
fracture.
27816............ Treatment of ankle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27818............ Treatment of ankle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
27822............ Treatment of ankle Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
fracture.
27823............ Treatment of ankle Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
fracture.
27824............ Treat lower leg fracture Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27825............ Treat lower leg fracture Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27826............ Treat lower leg fracture Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
27827............ Treat lower leg fracture Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
27828............ Treat lower leg fracture Y................ ................. A2............... $630.00 59.2233 $2,451.90 $1,085.48
27829............ Treat lower leg joint... Y................ ................. A2............... $446.00 41.1091 $1,701.96 $759.99
27830............ Treat lower leg Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
dislocation.
27831............ Treat lower leg Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
dislocation.
27832............ Treat lower leg Y................ ................. A2............... $446.00 41.1091 $1,701.96 $759.99
dislocation.
27840............ Treat ankle dislocation. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
27842............ Treat ankle dislocation. Y................ ................. A2............... $333.00 14.7658 $611.32 $402.58
27846............ Treat ankle dislocation. Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
27848............ Treat ankle dislocation. Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
27860............ Fixation of ankle joint. Y................ ................. A2............... $333.00 14.7658 $611.32 $402.58
27870............ Fusion of ankle joint, Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
open.
27871............ Fusion of tibiofibular Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
joint.
27884............ Amputation follow-up Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
surgery.
27889............ Amputation of foot at Y................ ................. A2............... $510.00 29.19 $1,208.50 $684.63
ankle.
27892............ Decompression of leg.... Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
27893............ Decompression of leg.... Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
27894............ Decompression of leg.... Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
28001............ Drainage of bursa of Y................ ................. P3............... ........... 2.8719 $118.90 $118.90
foot.
28002............ Treatment of foot Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
infection.
28003............ Treatment of foot Y................ ................. A2............... $510.00 21.2689 $880.55 $602.64
infection.
28005............ Treat foot bone lesion.. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28008............ Incision of foot fascia. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28010............ Incision of toe tendon.. Y................ ................. P3............... ........... 2.156 $89.26 $89.26
28011............ Incision of toe tendons. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28020............ Exploration of foot Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
joint.
28022............ Exploration of foot Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
joint.
28024............ Exploration of toe joint Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
28035............ Decompression of tibia Y................ ................. A2............... $630.00 18.0518 $747.36 $659.34
nerve.
28043............ Excision of foot lesion. Y................ ................. A2............... $446.00 21.1098 $873.97 $552.99
28045............ Excision of foot lesion. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28046............ Resection of tumor, foot Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28050............ Biopsy of foot joint Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
lining.
28052............ Biopsy of foot joint Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
lining.
28054............ Biopsy of toe joint Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
lining.
28055............ Neurectomy, foot........ Y................ ................. A2............... $630.00 18.0518 $747.36 $659.34
28060............ Partial removal, foot Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
fascia.
28062............ Removal of foot fascia.. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28070............ Removal of foot joint Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
lining.
28072............ Removal of foot joint Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
lining.
28080............ Removal of foot lesion.. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28086............ Excise foot tendon Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
sheath.
28088............ Excise foot tendon Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
sheath.
28090............ Removal of foot lesion.. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
[[Page 66964]]
28092............ Removal of toe lesions.. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28100............ Removal of ankle/heel Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
lesion.
28102............ Remove/graft foot lesion Y................ ................. A2............... $510.00 44.2687 $1,832.77 $840.69
28103............ Remove/graft foot lesion Y................ ................. A2............... $510.00 44.2687 $1,832.77 $840.69
28104............ Removal of foot lesion.. Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
28106............ Remove/graft foot lesion Y................ ................. A2............... $510.00 44.2687 $1,832.77 $840.69
28107............ Remove/graft foot lesion Y................ ................. A2............... $510.00 44.2687 $1,832.77 $840.69
28108............ Removal of toe lesions.. Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
28110............ Part removal of Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
metatarsal.
28111............ Part removal of Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
metatarsal.
28112............ Part removal of Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
metatarsal.
28113............ Part removal of Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
metatarsal.
28114............ Removal of metatarsal Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
heads.
28116............ Revision of foot........ Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28118............ Removal of heel bone.... Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
28119............ Removal of heel spur.... Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
28120............ Part removal of ankle/ Y................ ................. A2............... $995.00 20.8284 $862.32 $961.83
heel.
28122............ Partial removal of foot Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
bone.
28124............ Partial removal of toe.. Y................ ................. P3............... ........... 4.8385 $200.32 $200.32
28126............ Partial removal of toe.. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28130............ Removal of ankle bone... Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28140............ Removal of metatarsal... Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28150............ Removal of toe.......... Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28153............ Partial removal of toe.. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28160............ Partial removal of toe.. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28171............ Extensive foot surgery.. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28173............ Extensive foot surgery.. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28175............ Extensive foot surgery.. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28190............ Removal of foot foreign Y................ ................. P3............... ........... 3.0446 $126.05 $126.05
body.
28192............ Removal of foot foreign Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
body.
28193............ Removal of foot foreign Y................ ................. A2............... $418.49 8.685 $359.57 $403.76
body.
28200............ Repair of foot tendon... Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28202............ Repair/graft of foot Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
tendon.
28208............ Repair of foot tendon... Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28210............ Repair/graft of foot Y................ ................. A2............... $510.00 44.2687 $1,832.77 $840.69
tendon.
28220............ Release of foot tendon.. Y................ ................. P3............... ........... 4.5588 $188.74 $188.74
28222............ Release of foot tendons. Y................ ................. A2............... $333.00 20.8284 $862.32 $465.33
28225............ Release of foot tendon.. Y................ ................. A2............... $333.00 20.8284 $862.32 $465.33
28226............ Release of foot tendons. Y................ ................. A2............... $333.00 20.8284 $862.32 $465.33
28230............ Incision of foot Y................ ................. P3............... ........... 4.4929 $186.01 $186.01
tendon(s).
28232............ Incision of toe tendon.. Y................ ................. P3............... ........... 4.2955 $177.84 $177.84
28234............ Incision of foot tendon. Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
28238............ Revision of foot tendon. Y................ ................. A2............... $510.00 44.2687 $1,832.77 $840.69
28240............ Release of big toe...... Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
28250............ Revision of foot fascia. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28260............ Release of midfoot joint Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28261............ Revision of foot tendon. Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28262............ Revision of foot and Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
ankle.
28264............ Release of midfoot joint Y................ ................. A2............... $333.00 44.2687 $1,832.77 $707.94
28270............ Release of foot Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
contracture.
28272............ Release of toe joint, Y................ ................. P3............... ........... 4.1144 $170.34 $170.34
each.
28280............ Fusion of toes.......... Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
28285............ Repair of hammertoe..... Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28286............ Repair of hammertoe..... Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
28288............ Partial removal of foot Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
bone.
28289............ Repair hallux rigidus... Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28290............ Correction of bunion.... Y................ ................. A2............... $446.00 29.4167 $1,217.88 $638.97
28292............ Correction of bunion.... Y................ ................. A2............... $446.00 29.4167 $1,217.88 $638.97
28293............ Correction of bunion.... Y................ ................. A2............... $510.00 29.4167 $1,217.88 $686.97
28294............ Correction of bunion.... Y................ ................. A2............... $510.00 29.4167 $1,217.88 $686.97
28296............ Correction of bunion.... Y................ ................. A2............... $510.00 29.4167 $1,217.88 $686.97
28297............ Correction of bunion.... Y................ ................. A2............... $510.00 29.4167 $1,217.88 $686.97
28298............ Correction of bunion.... Y................ ................. A2............... $510.00 29.4167 $1,217.88 $686.97
28299............ Correction of bunion.... Y................ ................. A2............... $717.00 29.4167 $1,217.88 $842.22
28300............ Incision of heel bone... Y................ ................. A2............... $446.00 44.2687 $1,832.77 $792.69
28302............ Incision of ankle bone.. Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
28304............ Incision of midfoot Y................ ................. A2............... $446.00 44.2687 $1,832.77 $792.69
bones.
28305............ Incise/graft midfoot Y................ ................. A2............... $510.00 44.2687 $1,832.77 $840.69
bones.
28306............ Incision of metatarsal.. Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
28307............ Incision of metatarsal.. Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
28308............ Incision of metatarsal.. Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
28309............ Incision of metatarsals. Y................ ................. A2............... $630.00 44.2687 $1,832.77 $930.69
28310............ Revision of big toe..... Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
[[Page 66965]]
28312............ Revision of toe......... Y................ ................. A2............... $510.00 20.8284 $862.32 $598.08
28313............ Repair deformity of toe. Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
28315............ Removal of sesamoid bone Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
28320............ Repair of foot bones.... Y................ ................. A2............... $630.00 44.2687 $1,832.77 $930.69
28322............ Repair of metatarsals... Y................ ................. A2............... $630.00 44.2687 $1,832.77 $930.69
28340............ Resect enlarged toe Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
tissue.
28341............ Resect enlarged toe..... Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
28344............ Repair extra toe(s)..... Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
28345............ Repair webbed toe(s).... Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
28400............ Treatment of heel Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
28405............ Treatment of heel Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
28406............ Treatment of heel Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
fracture.
28415............ Treat heel fracture..... Y................ ................. A2............... $510.00 59.2233 $2,451.90 $995.48
28420............ Treat/graft heel Y................ ................. A2............... $630.00 41.1091 $1,701.96 $897.99
fracture.
28430............ Treatment of ankle Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
fracture.
28435............ Treatment of ankle Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
fracture.
28436............ Treatment of ankle Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
fracture.
28445............ Treat ankle fracture.... Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
28446............ Osteochondral talus Y................ NI............... G2............... ........... 44.2687 $1,832.77 $1,832.77
autogrft.
28450............ Treat midfoot fracture, Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
each.
28455............ Treat midfoot fracture, Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
each.
28456............ Treat midfoot fracture.. Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
28465............ Treat midfoot fracture, Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
each.
28470............ Treat metatarsal Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
fracture.
28475............ Treat metatarsal Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
fracture.
28476............ Treat metatarsal Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
fracture.
28485............ Treat metatarsal Y................ ................. A2............... $630.00 41.1091 $1,701.96 $897.99
fracture.
28490............ Treat big toe fracture.. Y................ ................. P3............... ........... 1.6869 $69.84 $69.84
28495............ Treat big toe fracture.. Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
28496............ Treat big toe fracture.. Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
28505............ Treat big toe fracture.. Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
28510............ Treatment of toe Y................ ................. P3............... ........... 1.3166 $54.51 $54.51
fracture.
28515............ Treatment of toe Y................ ................. P3............... ........... 1.6951 $70.18 $70.18
fracture.
28525............ Treat toe fracture...... Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
28530............ Treat sesamoid bone Y................ ................. P3............... ........... 1.2589 $52.12 $52.12
fracture.
28531............ Treat sesamoid bone Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
fracture.
28540............ Treat foot dislocation.. Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
28545............ Treat foot dislocation.. Y................ ................. A2............... $333.00 26.1592 $1,083.02 $520.51
28546............ Treat foot dislocation.. Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
28555............ Repair foot dislocation. Y................ ................. A2............... $446.00 41.1091 $1,701.96 $759.99
28570............ Treat foot dislocation.. Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
28575............ Treat foot dislocation.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
28576............ Treat foot dislocation.. Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
28585............ Repair foot dislocation. Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
28600............ Treat foot dislocation.. Y................ ................. P2............... ........... 1.7682 $73.21 $73.21
28605............ Treat foot dislocation.. Y................ ................. A2............... $103.62 1.7682 $73.21 $96.02
28606............ Treat foot dislocation.. Y................ ................. A2............... $446.00 26.1592 $1,083.02 $605.26
28615............ Repair foot dislocation. Y................ ................. A2............... $510.00 41.1091 $1,701.96 $807.99
28630............ Treat toe dislocation... Y................ CH............... P3............... ........... 1.399 $57.92 $57.92
28635............ Treat toe dislocation... Y................ ................. A2............... $333.00 14.7658 $611.32 $402.58
28636............ Treat toe dislocation... Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
28645............ Repair toe dislocation.. Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
28660............ Treat toe dislocation... Y................ CH............... P3............... ........... 1.0534 $43.61 $43.61
28665............ Treat toe dislocation... Y................ ................. A2............... $333.00 14.7658 $611.32 $402.58
28666............ Treat toe dislocation... Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
28675............ Repair of toe Y................ ................. A2............... $510.00 26.1592 $1,083.02 $653.26
dislocation.
28705............ Fusion of foot bones.... Y................ ................. A2............... $630.00 44.2687 $1,832.77 $930.69
28715............ Fusion of foot bones.... Y................ ................. A2............... $630.00 79.4244 $3,288.25 $1,294.56
28725............ Fusion of foot bones.... Y................ ................. A2............... $630.00 44.2687 $1,832.77 $930.69
28730............ Fusion of foot bones.... Y................ ................. A2............... $630.00 44.2687 $1,832.77 $930.69
28735............ Fusion of foot bones.... Y................ ................. A2............... $630.00 44.2687 $1,832.77 $930.69
28737............ Revision of foot bones.. Y................ ................. A2............... $717.00 44.2687 $1,832.77 $995.94
28740............ Fusion of foot bones.... Y................ ................. A2............... $630.00 44.2687 $1,832.77 $930.69
28750............ Fusion of big toe joint. Y................ ................. A2............... $630.00 44.2687 $1,832.77 $930.69
28755............ Fusion of big toe joint. Y................ ................. A2............... $630.00 20.8284 $862.32 $688.08
28760............ Fusion of big toe joint. Y................ ................. A2............... $630.00 44.2687 $1,832.77 $930.69
28810............ Amputation toe & Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
metatarsal.
28820............ Amputation of toe....... Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
28825............ Partial amputation of Y................ ................. A2............... $446.00 20.8284 $862.32 $550.08
toe.
28890*........... High energy eswt, Y................ CH............... P3............... ........... 4.2296 $175.11 $175.11
plantar f.
29000............ Application of body cast N................ ................. G2............... ........... 1.0931 $45.26 $45.26
29010............ Application of body cast N................ ................. P2............... ........... 2.291 $94.85 $94.85
29015............ Application of body cast N................ ................. P2............... ........... 2.291 $94.85 $94.85
[[Page 66966]]
29020............ Application of body cast N................ ................. G2............... ........... 1.0931 $45.26 $45.26
29025............ Application of body cast N................ ................. P2............... ........... 1.0931 $45.26 $45.26
29035............ Application of body cast N................ CH............... P2............... ........... 2.291 $94.85 $94.85
29040............ Application of body cast N................ ................. G2............... ........... 1.0931 $45.26 $45.26
29044............ Application of body cast N................ ................. P2............... ........... 2.291 $94.85 $94.85
29046............ Application of body cast N................ ................. G2............... ........... 2.291 $94.85 $94.85
29049............ Application of figure N................ ................. P3............... ........... 0.9956 $41.22 $41.22
eight.
29055............ Application of shoulder N................ ................. P2............... ........... 2.291 $94.85 $94.85
cast.
29058............ Application of shoulder N................ ................. P2............... ........... 1.0931 $45.26 $45.26
cast.
29065............ Application of long arm N................ ................. P3............... ........... 1.0698 $44.29 $44.29
cast.
29075............ Application of forearm N................ ................. P3............... ........... 1.0203 $42.24 $42.24
cast.
29085............ Apply hand/wrist cast... N................ ................. P3............... ........... 1.0451 $43.27 $43.27
29086............ Apply finger cast....... N................ ................. P3............... ........... 0.8394 $34.75 $34.75
29105............ Apply long arm splint... N................ ................. P3............... ........... 0.9546 $39.52 $39.52
29125............ Apply forearm splint.... N................ ................. P3............... ........... 0.8147 $33.73 $33.73
29126............ Apply forearm splint.... N................ ................. P3............... ........... 0.9135 $37.82 $37.82
29130............ Application of finger N................ ................. P3............... ........... 0.3703 $15.33 $15.33
splint.
29131............ Application of finger N................ ................. P3............... ........... 0.5432 $22.49 $22.49
splint.
29200............ Strapping of chest...... N................ ................. P3............... ........... 0.5432 $22.49 $22.49
29220............ Strapping of low back... N................ ................. P3............... ........... 0.5596 $23.17 $23.17
29240............ Strapping of shoulder... N................ ................. P3............... ........... 0.6253 $25.89 $25.89
29260............ Strapping of elbow or N................ ................. P3............... ........... 0.5761 $23.85 $23.85
wrist.
29280............ Strapping of hand or N................ ................. P3............... ........... 0.6007 $24.87 $24.87
finger.
29305............ Application of hip cast. N................ CH............... P2............... ........... 2.291 $94.85 $94.85
29325............ Application of hip casts N................ CH............... P2............... ........... 2.291 $94.85 $94.85
29345............ Application of long leg N................ ................. P3............... ........... 1.4072 $58.26 $58.26
cast.
29355............ Application of long leg N................ ................. P3............... ........... 1.3659 $56.55 $56.55
cast.
29358............ Apply long leg cast N................ ................. P3............... ........... 1.6705 $69.16 $69.16
brace.
29365............ Application of long leg N................ ................. P3............... ........... 1.3331 $55.19 $55.19
cast.
29405............ Apply short leg cast.... N................ ................. P3............... ........... 0.9874 $40.88 $40.88
29425............ Apply short leg cast.... N................ ................. P3............... ........... 1.0038 $41.56 $41.56
29435............ Apply short leg cast.... N................ ................. P3............... ........... 1.2674 $52.47 $52.47
29440............ Addition of walker to N................ ................. P3............... ........... 0.5514 $22.83 $22.83
cast.
29445............ Apply rigid leg cast.... N................ ................. P3............... ........... 1.3823 $57.23 $57.23
29450............ Application of leg cast. N................ ................. P2............... ........... 1.0931 $45.26 $45.26
29505............ Application, long leg N................ CH............... P3............... ........... 0.9217 $38.16 $38.16
splint.
29515............ Application lower leg N................ CH............... P3............... ........... 0.7488 $31.00 $31.00
splint.
29520............ Strapping of hip........ N................ ................. P3............... ........... 0.6171 $25.55 $25.55
29530............ Strapping of knee....... N................ ................. P3............... ........... 0.5925 $24.53 $24.53
29540............ Strapping of ankle and/ N................ ................. P3............... ........... 0.3949 $16.35 $16.35
or ft.
29550............ Strapping of toes....... N................ ................. P3............... ........... 0.4031 $16.69 $16.69
29580............ Application of paste N................ ................. P3............... ........... 0.5596 $23.17 $23.17
boot.
29590............ Application of foot N................ ................. P3............... ........... 0.4526 $18.74 $18.74
splint.
29700............ Removal/revision of cast N................ ................. P3............... ........... 0.757 $31.34 $31.34
29705............ Removal/revision of cast N................ ................. P3............... ........... 0.65 $26.91 $26.91
29710............ Removal/revision of cast N................ ................. P3............... ........... 1.1686 $48.38 $48.38
29715............ Removal/revision of cast N................ ................. P3............... ........... 0.971 $40.20 $40.20
29720............ Repair of body cast..... N................ ................. P3............... ........... 0.9546 $39.52 $39.52
29730............ Windowing of cast....... N................ ................. P3............... ........... 0.6336 $26.23 $26.23
29740............ Wedging of cast......... N................ ................. P3............... ........... 0.8968 $37.13 $37.13
29750............ Wedging of clubfoot cast N................ ................. P3............... ........... 0.8722 $36.11 $36.11
29800............ Jaw arthroscopy/surgery. Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29804............ Jaw arthroscopy/surgery. Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29805............ Shoulder arthroscopy, dx Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29806............ Shoulder arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29807............ Shoulder arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29819............ Shoulder arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29820............ Shoulder arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29821............ Shoulder arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29822............ Shoulder arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29823............ Shoulder arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29824............ Shoulder arthroscopy/ Y................ ................. A2............... $717.00 28.7803 $1,191.53 $835.63
surgery.
29825............ Shoulder arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29826............ Shoulder arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29827............ Arthroscop rotator cuff Y................ ................. A2............... $717.00 45.7072 $1,892.32 $1,010.83
repr.
29828............ Arthroscopy biceps Y................ NI............... G2............... ........... 45.7072 $1,892.32 $1,892.32
tenodesis.
29830............ Elbow arthroscopy....... Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29834............ Elbow arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29835............ Elbow arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29836............ Elbow arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29837............ Elbow arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29838............ Elbow arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29840............ Wrist arthroscopy....... Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
[[Page 66967]]
29843............ Wrist arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29844............ Wrist arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29845............ Wrist arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29846............ Wrist arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29847............ Wrist arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29848............ Wrist endoscopy/surgery. Y................ ................. A2............... $1,339.00 28.7803 $1,191.53 $1,302.13
29850............ Knee arthroscopy/surgery Y................ ................. A2............... $630.00 28.7803 $1,191.53 $770.38
29851............ Knee arthroscopy/surgery Y................ ................. A2............... $630.00 45.7072 $1,892.32 $945.58
29855............ Tibial arthroscopy/ Y................ ................. A2............... $630.00 45.7072 $1,892.32 $945.58
surgery.
29856............ Tibial arthroscopy/ Y................ ................. A2............... $630.00 45.7072 $1,892.32 $945.58
surgery.
29860............ Hip arthroscopy, dx..... Y................ ................. A2............... $630.00 45.7072 $1,892.32 $945.58
29861............ Hip arthroscopy/surgery. Y................ ................. A2............... $630.00 45.7072 $1,892.32 $945.58
29862............ Hip arthroscopy/surgery. Y................ ................. A2............... $1,339.00 45.7072 $1,892.32 $1,477.33
29863............ Hip arthroscopy/surgery. Y................ ................. A2............... $630.00 45.7072 $1,892.32 $945.58
29866............ Autgrft implnt, knee w/ Y................ CH............... G2............... ........... 45.7072 $1,892.32 $1,892.32
scope.
29870............ Knee arthroscopy, dx.... Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29871............ Knee arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
drainage.
29873............ Knee arthroscopy/surgery Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29874............ Knee arthroscopy/surgery Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29875............ Knee arthroscopy/surgery Y................ ................. A2............... $630.00 28.7803 $1,191.53 $770.38
29876............ Knee arthroscopy/surgery Y................ ................. A2............... $630.00 28.7803 $1,191.53 $770.38
29877............ Knee arthroscopy/surgery Y................ ................. A2............... $630.00 28.7803 $1,191.53 $770.38
29879............ Knee arthroscopy/surgery Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29880............ Knee arthroscopy/surgery Y................ ................. A2............... $630.00 28.7803 $1,191.53 $770.38
29881............ Knee arthroscopy/surgery Y................ ................. A2............... $630.00 28.7803 $1,191.53 $770.38
29882............ Knee arthroscopy/surgery Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29883............ Knee arthroscopy/surgery Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29884............ Knee arthroscopy/surgery Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29885............ Knee arthroscopy/surgery Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
29886............ Knee arthroscopy/surgery Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29887............ Knee arthroscopy/surgery Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
29888............ Knee arthroscopy/surgery Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
29889............ Knee arthroscopy/surgery Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
29891............ Ankle arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29892............ Ankle arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29893............ Scope, plantar Y................ ................. A2............... $1,255.56 20.8284 $862.32 $1,157.25
fasciotomy.
29894............ Ankle arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29895............ Ankle arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29897............ Ankle arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29898............ Ankle arthroscopy/ Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surgery.
29899............ Ankle arthroscopy/ Y................ ................. A2............... $510.00 45.7072 $1,892.32 $855.58
surgery.
29900............ Mcp joint arthroscopy, Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
dx.
29901............ Mcp joint arthroscopy, Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surg.
29902............ Mcp joint arthroscopy, Y................ ................. A2............... $510.00 28.7803 $1,191.53 $680.38
surg.
29904............ Subtalar arthro w/fb Y................ NI............... G2............... ........... 28.7803 $1,191.53 $1,191.53
rmvl.
29905............ Subtalar arthro w/exc... Y................ NI............... G2............... ........... 28.7803 $1,191.53 $1,191.53
29906............ Subtalar arthro w/deb... Y................ NI............... G2............... ........... 28.7803 $1,191.53 $1,191.53
29907............ Subtalar arthro w/fusion Y................ NI............... G2............... ........... 45.7072 $1,892.32 $1,892.32
30000............ Drainage of nose lesion. Y................ ................. P2............... ........... 2.5002 $103.51 $103.51
30020............ Drainage of nose lesion. Y................ ................. P2............... ........... 2.5002 $103.51 $103.51
30100............ Intranasal biopsy....... Y................ ................. P3............... ........... 1.8763 $77.68 $77.68
30110............ Removal of nose polyp(s) Y................ ................. P3............... ........... 2.9376 $121.62 $121.62
30115............ Removal of nose polyp(s) Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
30117............ Removal of intranasal Y................ ................. A2............... $510.00 16.3288 $676.03 $551.51
lesion.
30118............ Removal of intranasal Y................ ................. A2............... $510.00 23.9765 $992.65 $630.66
lesion.
30120............ Revision of nose........ Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
30124............ Removal of nose lesion.. Y................ ................. R2............... ........... 7.4474 $308.33 $308.33
30125............ Removal of nose lesion.. Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
30130............ Excise inferior Y................ ................. A2............... $510.00 16.3288 $676.03 $551.51
turbinate.
30140............ Resect inferior Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
turbinate.
30150............ Partial removal of nose. Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
30160............ Removal of nose......... Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
30200............ Injection treatment of Y................ ................. P3............... ........... 1.4975 $62.00 $62.00
nose.
30210............ Nasal sinus therapy..... Y................ ................. P3............... ........... 1.8927 $78.36 $78.36
30220............ Insert nasal septal Y................ ................. A2............... $464.15 7.4474 $308.33 $425.20
button.
30300............ Remove nasal foreign N................ ................. P2............... ........... 0.631 $26.12 $26.12
body.
30310............ Remove nasal foreign Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
body.
30320............ Remove nasal foreign Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
body.
30400............ Reconstruction of nose.. Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
30410............ Reconstruction of nose.. Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
30420............ Reconstruction of nose.. Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
30430............ Revision of nose........ Y................ ................. A2............... $510.00 23.9765 $992.65 $630.66
30435............ Revision of nose........ Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
[[Page 66968]]
30450............ Revision of nose........ Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
30460............ Revision of nose........ Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
30462............ Revision of nose........ Y................ ................. A2............... $1,339.00 39.8776 $1,650.97 $1,416.99
30465............ Repair nasal stenosis... Y................ ................. A2............... $1,339.00 39.8776 $1,650.97 $1,416.99
30520............ Repair of nasal septum.. Y................ ................. A2............... $630.00 23.9765 $992.65 $720.66
30540............ Repair nasal defect..... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
30545............ Repair nasal defect..... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
30560............ Release of nasal Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
adhesions.
30580............ Repair upper jaw fistula Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
30600............ Repair mouth/nose Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
fistula.
30620............ Intranasal Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
reconstruction.
30630............ Repair nasal septum Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
defect.
30801............ Ablate inf turbinate, Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
superf.
30802............ Cauterization, inner Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
nose.
30901............ Control of nosebleed.... Y................ ................. P3............... ........... 1.078 $44.63 $44.63
30903............ Control of nosebleed.... Y................ ................. A2............... $72.48 1.1251 $46.58 $66.01
30905............ Control of nosebleed.... Y................ ................. A2............... $72.48 1.1251 $46.58 $66.01
30906............ Repeat control of Y................ ................. A2............... $72.48 1.1251 $46.58 $66.01
nosebleed.
30915............ Ligation, nasal sinus Y................ ................. A2............... $446.00 25.841 $1,069.84 $601.96
artery.
30920............ Ligation, upper jaw Y................ ................. A2............... $510.00 25.841 $1,069.84 $649.96
artery.
30930............ Ther fx, nasal inf Y................ ................. A2............... $630.00 16.3288 $676.03 $641.51
turbinate.
31000............ Irrigation, maxillary Y................ ................. P3............... ........... 2.4934 $103.23 $103.23
sinus.
31002............ Irrigation, sphenoid Y................ ................. R2............... ........... 7.4474 $308.33 $308.33
sinus.
31020............ Exploration, maxillary Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
sinus.
31030............ Exploration, maxillary Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
sinus.
31032............ Explore sinus, remove Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
polyps.
31040............ Exploration behind upper Y................ ................. R2............... ........... 23.9765 $992.65 $992.65
jaw.
31050............ Exploration, sphenoid Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
sinus.
31051............ Sphenoid sinus surgery.. Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
31070............ Exploration of frontal Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
sinus.
31075............ Exploration of frontal Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
sinus.
31080............ Removal of frontal sinus Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
31081............ Removal of frontal sinus Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
31084............ Removal of frontal sinus Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
31085............ Removal of frontal sinus Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
31086............ Removal of frontal sinus Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
31087............ Removal of frontal sinus Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
31090............ Exploration of sinuses.. Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
31200............ Removal of ethmoid sinus Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
31201............ Removal of ethmoid sinus Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
31205............ Removal of ethmoid sinus Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
31231............ Nasal endoscopy, dx..... Y................ ................. P2............... ........... 1.6115 $66.72 $66.72
31233............ Nasal/sinus endoscopy, Y................ ................. A2............... $86.39 1.6115 $66.72 $81.47
dx.
31235............ Nasal/sinus endoscopy, Y................ ................. A2............... $333.00 17.016 $704.48 $425.87
dx.
31237............ Nasal/sinus endoscopy, Y................ ................. A2............... $446.00 17.016 $704.48 $510.62
surg.
31238............ Nasal/sinus endoscopy, Y................ ................. A2............... $333.00 17.016 $704.48 $425.87
surg.
31239............ Nasal/sinus endoscopy, Y................ ................. A2............... $630.00 22.7191 $940.59 $707.65
surg.
31240............ Nasal/sinus endoscopy, Y................ ................. A2............... $446.00 17.016 $704.48 $510.62
surg.
31254............ Revision of ethmoid Y................ ................. A2............... $510.00 22.7191 $940.59 $617.65
sinus.
31255............ Removal of ethmoid sinus Y................ ................. A2............... $717.00 22.7191 $940.59 $772.90
31256............ Exploration maxillary Y................ ................. A2............... $510.00 22.7191 $940.59 $617.65
sinus.
31267............ Endoscopy, maxillary Y................ ................. A2............... $510.00 22.7191 $940.59 $617.65
sinus.
31276............ Sinus endoscopy, Y................ ................. A2............... $510.00 22.7191 $940.59 $617.65
surgical.
31287............ Nasal/sinus endoscopy, Y................ ................. A2............... $510.00 22.7191 $940.59 $617.65
surg.
31288............ Nasal/sinus endoscopy, Y................ ................. A2............... $510.00 22.7191 $940.59 $617.65
surg.
31300............ Removal of larynx lesion Y................ ................. A2............... $717.00 23.9765 $992.65 $785.91
31320............ Diagnostic incision, Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
larynx.
31400............ Revision of larynx...... Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
31420............ Removal of epiglottis... Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
31500............ Insert emergency airway. N................ ................. G2............... ........... 2.459 $101.81 $101.81
31502............ Change of windpipe N................ ................. G2............... ........... 1.3362 $55.32 $55.32
airway.
31505............ Diagnostic laryngoscopy. Y................ ................. P2............... ........... 0.8224 $34.05 $34.05
31510............ Laryngoscopy with biopsy Y................ ................. A2............... $446.00 17.016 $704.48 $510.62
31511............ Remove foreign body, Y................ ................. A2............... $86.39 1.6115 $66.72 $81.47
larynx.
31512............ Removal of larynx lesion Y................ ................. A2............... $446.00 17.016 $704.48 $510.62
31513............ Injection into vocal Y................ ................. A2............... $86.39 1.6115 $66.72 $81.47
cord.
31515............ Laryngoscopy for Y................ ................. A2............... $333.00 17.016 $704.48 $425.87
aspiration.
31520............ Dx laryngoscopy, newborn Y................ ................. G2............... ........... 1.6115 $66.72 $66.72
31525............ Dx laryngoscopy excl nb. Y................ ................. A2............... $333.00 17.016 $704.48 $425.87
31526............ Dx laryngoscopy w/oper Y................ ................. A2............... $446.00 22.7191 $940.59 $569.65
scope.
31527............ Laryngoscopy for Y................ ................. A2............... $333.00 22.7191 $940.59 $484.90
treatment.
31528............ Laryngoscopy and Y................ ................. A2............... $446.00 17.016 $704.48 $510.62
dilation.
31529............ Laryngoscopy and Y................ ................. A2............... $446.00 17.016 $704.48 $510.62
dilation.
[[Page 66969]]
31530............ Laryngoscopy w/fb Y................ ................. A2............... $446.00 22.7191 $940.59 $569.65
removal.
31531............ Laryngoscopy w/fb & op Y................ ................. A2............... $510.00 22.7191 $940.59 $617.65
scope.
31535............ Laryngoscopy w/biopsy... Y................ ................. A2............... $446.00 22.7191 $940.59 $569.65
31536............ Laryngoscopy w/bx & op Y................ ................. A2............... $510.00 22.7191 $940.59 $617.65
scope.
31540............ Laryngoscopy w/exc of Y................ ................. A2............... $510.00 22.7191 $940.59 $617.65
tumor.
31541............ Larynscop w/tumr exc + Y................ ................. A2............... $630.00 22.7191 $940.59 $707.65
scope.
31545............ Remove vc lesion w/scope Y................ ................. A2............... $630.00 22.7191 $940.59 $707.65
31546............ Remove vc lesion scope/ Y................ ................. A2............... $630.00 22.7191 $940.59 $707.65
graft.
31560............ Laryngoscop w/ Y................ ................. A2............... $717.00 22.7191 $940.59 $772.90
arytenoidectom.
31561............ Larynscop, remve cart + Y................ ................. A2............... $717.00 22.7191 $940.59 $772.90
scop.
31570............ Laryngoscope w/vc inj... Y................ ................. A2............... $446.00 17.016 $704.48 $510.62
31571............ Laryngoscop w/vc inj + Y................ ................. A2............... $446.00 22.7191 $940.59 $569.65
scope.
31575............ Diagnostic laryngoscopy. Y................ ................. P3............... ........... 1.4811 $61.32 $61.32
31576............ Laryngoscopy with biopsy Y................ ................. A2............... $446.00 22.7191 $940.59 $569.65
31577............ Remove foreign body, Y................ ................. A2............... $236.42 3.994 $165.36 $218.66
larynx.
31578............ Removal of larynx lesion Y................ ................. A2............... $446.00 22.7191 $940.59 $569.65
31579............ Diagnostic laryngoscopy. Y................ ................. P3............... ........... 2.7321 $113.11 $113.11
31580............ Revision of larynx...... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
31582............ Revision of larynx...... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
31588............ Revision of larynx...... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
31590............ Reinnervate larynx...... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
31595............ Larynx nerve surgery.... Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
31603............ Incision of windpipe.... Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
31605............ Incision of windpipe.... Y................ ................. G2............... ........... 7.4474 $308.33 $308.33
31611............ Surgery/speech Y................ ................. A2............... $510.00 23.9765 $992.65 $630.66
prosthesis.
31612............ Puncture/clear windpipe. Y................ ................. A2............... $333.00 23.9765 $992.65 $497.91
31613............ Repair windpipe opening. Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
31614............ Repair windpipe opening. Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
31615............ Visualization of Y................ ................. A2............... $333.00 9.9575 $412.25 $352.81
windpipe.
31620............ Endobronchial us add-on. N................ CH............... N1............... ........... ........... ........... ...........
31622............ Dx bronchoscope/wash.... Y................ ................. A2............... $333.00 9.9575 $412.25 $352.81
31623............ Dx bronchoscope/brush... Y................ ................. A2............... $446.00 9.9575 $412.25 $437.56
31624............ Dx bronchoscope/lavage.. Y................ ................. A2............... $446.00 9.9575 $412.25 $437.56
31625............ Bronchoscopy w/biopsy(s) Y................ ................. A2............... $446.00 9.9575 $412.25 $437.56
31628............ Bronchoscopy/lung bx, Y................ ................. A2............... $446.00 9.9575 $412.25 $437.56
each.
31629............ Bronchoscopy/needle bx, Y................ ................. A2............... $446.00 9.9575 $412.25 $437.56
each.
31630............ Bronchoscopy dilate/fx Y................ ................. A2............... $446.00 24.0654 $996.33 $583.58
repr.
31631............ Bronchoscopy, dilate w/ Y................ ................. A2............... $446.00 24.0654 $996.33 $583.58
stent.
31632............ Bronchoscopy/lung bx, Y................ ................. G2............... ........... 9.9575 $412.25 $412.25
add?l.
31633............ Bronchoscopy/needle bx Y................ ................. G2............... ........... 9.9575 $412.25 $412.25
add?l.
31635............ Bronchoscopy w/fb Y................ ................. A2............... $446.00 9.9575 $412.25 $437.56
removal.
31636............ Bronchoscopy, bronch Y................ ................. A2............... $446.00 24.0654 $996.33 $583.58
stents.
31637............ Bronchoscopy, stent add- Y................ ................. A2............... $333.00 9.9575 $412.25 $352.81
on.
31638............ Bronchoscopy, revise Y................ ................. A2............... $446.00 24.0654 $996.33 $583.58
stent.
31640............ Bronchoscopy w/tumor Y................ ................. A2............... $446.00 24.0654 $996.33 $583.58
excise.
31641............ Bronchoscopy, treat Y................ ................. A2............... $446.00 24.0654 $996.33 $583.58
blockage.
31643............ Diag bronchoscope/ Y................ ................. A2............... $446.00 9.9575 $412.25 $437.56
catheter.
31645............ Bronchoscopy, clear Y................ ................. A2............... $333.00 9.9575 $412.25 $352.81
airways.
31646............ Bronchoscopy, reclear Y................ ................. A2............... $333.00 9.9575 $412.25 $352.81
airway.
31656............ Bronchoscopy, inj for x- Y................ ................. A2............... $333.00 9.9575 $412.25 $352.81
ray.
31715............ Injection for bronchus x- N................ ................. N1............... ........... ........... ........... ...........
ray.
31717............ Bronchial brush biopsy.. Y................ ................. A2............... $236.42 3.994 $165.36 $218.66
31720............ Clearance of airways.... N................ ................. A2............... $47.32 0.3877 $16.05 $39.50
31730............ Intro, windpipe wire/ Y................ ................. A2............... $236.42 3.994 $165.36 $218.66
tube.
31750............ Repair of windpipe...... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
31755............ Repair of windpipe...... Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
31820............ Closure of windpipe Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
lesion.
31825............ Repair of windpipe Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
defect.
31830............ Revise windpipe scar.... Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
32000............ Drainage of chest....... N................ CH............... D5............... ........... ........... ........... ...........
32002............ Treatment of collapsed N................ CH............... D5............... ........... ........... ........... ...........
lung.
32019............ Insert pleural catheter. N................ CH............... D5............... ........... ........... ........... ...........
32400............ Needle biopsy chest Y................ ................. A2............... $333.00 9.3354 $386.49 $346.37
lining.
32405............ Biopsy, lung or Y................ ................. A2............... $333.00 9.3354 $386.49 $346.37
mediastinum.
32420............ Puncture/clear lung..... Y................ ................. A2............... $222.78 5.2024 $215.38 $220.93
32421............ Thoracentesis for Y................ NI............... A2............... $222.78 5.2024 $215.38 $220.93
aspiration.
32422............ Thoracentesis w/tube Y................ NI............... G2............... ........... 5.2024 $215.38 $215.38
insert.
32550............ Insert pleural cath..... Y................ NI............... G2............... ........... 30.7096 $1,271.41 $1,271.41
32960............ Therapeutic pneumothorax Y................ ................. G2............... ........... 5.2024 $215.38 $215.38
32998............ Perq rf ablate tx, pul Y................ CH............... G2............... ........... 42.998 $1,780.16 $1,780.16
tumor.
33010............ Drainage of heart sac... Y................ ................. A2............... $222.78 5.2024 $215.38 $220.93
33011............ Repeat drainage of heart Y................ ................. A2............... $222.78 5.2024 $215.38 $220.93
sac.
33206............ Insertion of heart Y................ ................. J8............... ........... 169.4628 $7,015.93 $7,015.93
pacemaker.
[[Page 66970]]
33207............ Insertion of heart Y................ ................. J8............... ........... 169.4628 $7,015.93 $7,015.93
pacemaker.
33208............ Insertion of heart Y................ ................. J8............... ........... 196.2967 $8,126.88 $8,126.88
pacemaker.
33210............ Insertion of heart Y................ CH............... J8............... ........... 90.579 $3,750.06 $3,750.06
electrode.
33211............ Insertion of heart Y................ CH............... J8............... ........... 90.579 $3,750.06 $3,750.06
electrode.
33212............ Insertion of pulse Y................ ................. H8............... $510.00 142.1043 $5,883.26 $5,514.64
generator.
33213............ Insertion of pulse Y................ ................. H8............... $510.00 154.6733 $6,403.63 $6,010.06
generator.
33214............ Upgrade of pacemaker Y................ ................. J8............... ........... 196.2967 $8,126.88 $8,126.88
system.
33215............ Reposition pacing-defib Y................ ................. G2............... ........... 23.9802 $992.80 $992.80
lead.
33216............ Insert lead pace-defib, Y................ CH............... J8............... ........... 90.579 $3,750.06 $3,750.06
one.
33217............ Insert lead pace-defib, Y................ CH............... J8............... ........... 90.579 $3,750.06 $3,750.06
dual.
33218............ Repair lead pace-defib, Y................ ................. G2............... ........... 23.9802 $992.80 $992.80
one.
33220............ Repair lead pace-defib, Y................ ................. G2............... ........... 23.9802 $992.80 $992.80
dual.
33222............ Revise pocket, pacemaker Y................ ................. A2............... $446.00 15.0458 $622.91 $490.23
33223............ Revise pocket, pacing- Y................ ................. A2............... $446.00 15.0458 $622.91 $490.23
defib.
33224............ Insert pacing lead & Y................ ................. J8............... ........... 375.1658 $15,532.24 $15,532.24
connect.
33225............ L ventric pacing lead Y................ ................. J8............... ........... 375.1658 $15,532.24 $15,532.24
add-on.
33226............ Reposition l ventric Y................ ................. G2............... ........... 23.9802 $992.80 $992.80
lead.
33233............ Removal of pacemaker Y................ ................. A2............... $446.00 23.9802 $992.80 $582.70
system.
33234............ Removal of pacemaker Y................ ................. G2............... ........... 23.9802 $992.80 $992.80
system.
33235............ Removal pacemaker Y................ ................. G2............... ........... 23.9802 $992.80 $992.80
electrode.
33240............ Insert pulse generator.. Y................ CH............... J8............... ........... 493.9803 $20,451.28 $20,451.28
33241............ Remove pulse generator.. Y................ ................. G2............... ........... 23.9802 $992.80 $992.80
33249............ Eltrd/insert pace-defib. Y................ CH............... J8............... ........... 599.3974 $24,815.65 $24,815.65
33282............ Implant pat-active ht N................ ................. J8............... ........... 98.4186 $4,074.63 $4,074.63
record.
33284............ Remove pat-active ht Y................ ................. G2............... ........... 8.685 $359.57 $359.57
record.
33508............ Endoscopic vein harvest. N................ ................. N1............... ........... ........... ........... ...........
35188............ Repair blood vessel Y................ ................. A2............... $630.00 38.7673 $1,605.00 $873.75
lesion.
35207............ Repair blood vessel Y................ ................. A2............... $630.00 38.7673 $1,605.00 $873.75
lesion.
35473............ Repair arterial blockage Y................ ................. G2............... ........... 45.3845 $1,878.96 $1,878.96
35476............ Repair venous blockage.. Y................ ................. G2............... ........... 45.3845 $1,878.96 $1,878.96
35492............ Atherectomy, Y................ ................. G2............... ........... 87.5137 $3,623.15 $3,623.15
percutaneous.
35572............ Harvest femoropopliteal N................ ................. N1............... ........... ........... ........... ...........
vein.
35761............ Exploration of artery/ Y................ ................. G2............... ........... 29.6965 $1,229.46 $1,229.46
vein.
35875............ Removal of clot in graft Y................ ................. A2............... $1,339.00 38.7673 $1,605.00 $1,405.50
35876............ Removal of clot in graft Y................ ................. A2............... $1,339.00 38.7673 $1,605.00 $1,405.50
36000............ Place needle in vein.... N................ ................. N1............... ........... ........... ........... ...........
36002............ Pseudoaneurysm injection N................ ................. G2............... ........... 2.3792 $98.50 $98.50
trt.
36005............ Injection ext venography N................ ................. N1............... ........... ........... ........... ...........
36010............ Place catheter in vein.. N................ ................. N1............... ........... ........... ........... ...........
36011............ Place catheter in vein.. N................ ................. N1............... ........... ........... ........... ...........
36012............ Place catheter in vein.. N................ ................. N1............... ........... ........... ........... ...........
36013............ Place catheter in artery N................ ................. N1............... ........... ........... ........... ...........
36014............ Place catheter in artery N................ ................. N1............... ........... ........... ........... ...........
36015............ Place catheter in artery N................ ................. N1............... ........... ........... ........... ...........
36100............ Establish access to N................ ................. N1............... ........... ........... ........... ...........
artery.
36120............ Establish access to N................ ................. N1............... ........... ........... ........... ...........
artery.
36140............ Establish access to N................ ................. N1............... ........... ........... ........... ...........
artery.
36145............ Artery to vein shunt.... N................ ................. N1............... ........... ........... ........... ...........
36160............ Establish access to N................ ................. N1............... ........... ........... ........... ...........
aorta.
36200............ Place catheter in aorta. N................ ................. N1............... ........... ........... ........... ...........
36215............ Place catheter in artery N................ ................. N1............... ........... ........... ........... ...........
36216............ Place catheter in artery N................ ................. N1............... ........... ........... ........... ...........
36217............ Place catheter in artery N................ ................. N1............... ........... ........... ........... ...........
36218............ Place catheter in artery N................ ................. N1............... ........... ........... ........... ...........
36245............ Place catheter in artery N................ ................. N1............... ........... ........... ........... ...........
36246............ Place catheter in artery N................ ................. N1............... ........... ........... ........... ...........
36247............ Place catheter in artery N................ ................. N1............... ........... ........... ........... ...........
36248............ Place catheter in artery N................ ................. N1............... ........... ........... ........... ...........
36260............ Insertion of infusion Y................ ................. A2............... $510.00 28.8743 $1,195.42 $681.36
pump.
36261............ Revision of infusion Y................ ................. A2............... $446.00 23.9802 $992.80 $582.70
pump.
36262............ Removal of infusion pump Y................ ................. A2............... $333.00 23.9802 $992.80 $497.95
36400............ Bl draw < 3 yrs fem/ N................ ................. N1............... ........... ........... ........... ...........
jugular.
36405............ Bl draw < 3 yrs scalp N................ ................. N1............... ........... ........... ........... ...........
vein.
36406............ Bl draw < 3 yrs other N................ ................. N1............... ........... ........... ........... ...........
vein.
36410............ Non-routine bl draw > 3 N................ ................. N1............... ........... ........... ........... ...........
yrs.
36416............ Capillary blood draw.... N................ ................. N1............... ........... ........... ........... ...........
36420............ Vein access cutdown < 1 Y................ ................. G2............... ........... 0.2143 $8.87 $8.87
yr.
36425............ Vein access cutdown > 1 Y................ ................. R2............... ........... 0.2143 $8.87 $8.87
yr.
36430............ Blood transfusion N................ ................. P3............... ........... 0.7983 $33.05 $33.05
service.
36440............ Bl push transfuse, 2 yr N................ ................. R2............... ........... 3.3967 $140.63 $140.63
or <.
36450............ Bl exchange/transfuse, N................ ................. R2............... ........... 3.3967 $140.63 $140.63
nb.
36468............ Injection(s), spider Y................ ................. R2............... ........... 0.793 $32.83 $32.83
veins.
36469............ Injection(s), spider Y................ CH............... R2............... ........... 0.793 $32.83 $32.83
veins.
[[Page 66971]]
36470............ Injection therapy of Y................ ................. P2............... ........... 0.793 $32.83 $32.83
vein.
36471............ Injection therapy of Y................ ................. P2............... ........... 0.793 $32.83 $32.83
veins.
36475............ Endovenous rf, 1st vein. Y................ ................. A2............... $1,339.00 42.6114 $1,764.15 $1,445.29
36476............ Endovenous rf, vein add- Y................ ................. A2............... $1,339.00 25.841 $1,069.84 $1,271.71
on.
36478............ Endovenous laser, 1st Y................ ................. A2............... $1,339.00 25.841 $1,069.84 $1,271.71
vein.
36479............ Endovenous laser vein Y................ ................. A2............... $1,339.00 25.841 $1,069.84 $1,271.71
addon.
36481............ Insertion of catheter, N................ ................. N1............... ........... ........... ........... ...........
vein.
36500............ Insertion of catheter, N................ ................. N1............... ........... ........... ........... ...........
vein.
36510............ Insertion of catheter, N................ ................. N1............... ........... ........... ........... ...........
vein.
36511............ Apheresis wbc........... N................ ................. G2............... ........... 11.5058 $476.35 $476.35
36512............ Apheresis rbc........... N................ ................. G2............... ........... 11.5058 $476.35 $476.35
36513............ Apheresis platelets..... N................ ................. G2............... ........... 11.5058 $476.35 $476.35
36514............ Apheresis plasma........ N................ ................. G2............... ........... 11.5058 $476.35 $476.35
36515............ Apheresis, adsorp/ N................ ................. G2............... ........... 30.6035 $1,267.02 $1,267.02
reinfuse.
36516............ Apheresis, selective.... N................ ................. G2............... ........... 30.6035 $1,267.02 $1,267.02
36522............ Photopheresis........... N................ ................. G2............... ........... 30.6035 $1,267.02 $1,267.02
36540............ Collect blood venous N................ CH............... D5............... ........... ........... ........... ...........
device.
36550............ Declot vascular device.. N................ CH............... D5............... ........... ........... ........... ...........
36555............ Insert non-tunnel cv Y................ ................. A2............... $333.00 10.9092 $451.65 $362.66
cath.
36556............ Insert non-tunnel cv Y................ ................. A2............... $333.00 10.9092 $451.65 $362.66
cath.
36557............ Insert tunneled cv cath. Y................ ................. A2............... $446.00 24.1069 $998.05 $584.01
36558............ Insert tunneled cv cath. Y................ ................. A2............... $446.00 24.1069 $998.05 $584.01
36560............ Insert tunneled cv cath. Y................ ................. A2............... $510.00 28.8743 $1,195.42 $681.36
36561............ Insert tunneled cv cath. Y................ ................. A2............... $510.00 28.8743 $1,195.42 $681.36
36563............ Insert tunneled cv cath. Y................ ................. A2............... $510.00 28.8743 $1,195.42 $681.36
36565............ Insert tunneled cv cath. Y................ ................. A2............... $510.00 28.8743 $1,195.42 $681.36
36566............ Insert tunneled cv cath. Y................ ................. H8............... $510.00 107.6665 $4,457.50 $3,796.23
36568............ Insert picc cath........ Y................ ................. A2............... $333.00 10.9092 $451.65 $362.66
36569............ Insert picc cath........ Y................ ................. A2............... $333.00 10.9092 $451.65 $362.66
36570............ Insert picvad cath...... Y................ ................. A2............... $510.00 24.1069 $998.05 $632.01
36571............ Insert picvad cath...... Y................ ................. A2............... $510.00 24.1069 $998.05 $632.01
36575............ Repair tunneled cv cath. Y................ ................. A2............... $446.00 5.6614 $234.39 $393.10
36576............ Repair tunneled cv cath. Y................ ................. A2............... $446.00 10.9092 $451.65 $447.41
36578............ Replace tunneled cv cath Y................ ................. A2............... $446.00 24.1069 $998.05 $584.01
36580............ Replace cvad cath....... Y................ ................. A2............... $333.00 10.9092 $451.65 $362.66
36581............ Replace tunneled cv cath Y................ ................. A2............... $446.00 24.1069 $998.05 $584.01
36582............ Replace tunneled cv cath Y................ ................. A2............... $510.00 28.8743 $1,195.42 $681.36
36583............ Replace tunneled cv cath Y................ ................. A2............... $510.00 28.8743 $1,195.42 $681.36
36584............ Replace picc cath....... Y................ ................. A2............... $333.00 10.9092 $451.65 $362.66
36585............ Replace picvad cath..... Y................ ................. A2............... $510.00 24.1069 $998.05 $632.01
36589............ Removal tunneled cv cath Y................ ................. A2............... $333.00 5.6614 $234.39 $308.35
36590............ Removal tunneled cv cath Y................ ................. A2............... $333.00 10.9092 $451.65 $362.66
36591............ Draw blood off venous N................ NI............... N1............... ........... ........... ........... ...........
device.
36592............ Collect blood from picc. N................ NI............... N1............... ........... ........... ........... ...........
36593............ Declot vascular device.. Y................ NI............... P3............... ........... 0.4937 $20.44 $20.44
36595............ Mech remov tunneled cv Y................ ................. G2............... ........... 24.1069 $998.05 $998.05
cath.
36596............ Mech remov tunneled cv Y................ ................. G2............... ........... 10.9092 $451.65 $451.65
cath.
36597............ Reposition venous Y................ ................. G2............... ........... 10.9092 $451.65 $451.65
catheter.
36598............ Inj w/fluor, eval cv Y................ CH............... P3............... ........... 1.9997 $82.79 $82.79
device.
36600............ Withdrawal of arterial N................ ................. N1............... ........... ........... ........... ...........
blood.
36620............ Insertion catheter, N................ ................. N1............... ........... ........... ........... ...........
artery.
36625............ Insertion catheter, N................ ................. N1............... ........... ........... ........... ...........
artery.
36640............ Insertion catheter, Y................ ................. A2............... $333.00 28.8743 $1,195.42 $548.61
artery.
36680............ Insert needle, bone Y................ ................. G2............... ........... 1.1097 $45.94 $45.94
cavity.
36800............ Insertion of cannula.... Y................ ................. A2............... $510.00 29.6965 $1,229.46 $689.87
36810............ Insertion of cannula.... Y................ ................. A2............... $510.00 29.6965 $1,229.46 $689.87
36815............ Insertion of cannula.... Y................ ................. A2............... $510.00 29.6965 $1,229.46 $689.87
36818............ Av fuse, uppr arm, Y................ ................. A2............... $510.00 38.7673 $1,605.00 $783.75
cephalic.
36819............ Av fuse, uppr arm, Y................ ................. A2............... $510.00 38.7673 $1,605.00 $783.75
basilic.
36820............ Av fusion/forearm vein.. Y................ ................. A2............... $510.00 38.7673 $1,605.00 $783.75
36821............ Av fusion direct any Y................ ................. A2............... $510.00 38.7673 $1,605.00 $783.75
site.
36825............ Artery-vein autograft... Y................ ................. A2............... $630.00 38.7673 $1,605.00 $873.75
36830............ Artery-vein nonautograft Y................ ................. A2............... $630.00 38.7673 $1,605.00 $873.75
36831............ Open thrombect av Y................ ................. A2............... $1,339.00 38.7673 $1,605.00 $1,405.50
fistula.
36832............ Av fistula revision, Y................ ................. A2............... $630.00 38.7673 $1,605.00 $873.75
open.
36833............ Av fistula revision..... Y................ ................. A2............... $630.00 38.7673 $1,605.00 $873.75
36834............ Repair a-v aneurysm..... Y................ ................. A2............... $510.00 38.7673 $1,605.00 $783.75
36835............ Artery to vein shunt.... Y................ ................. A2............... $630.00 29.6965 $1,229.46 $779.87
36860............ External cannula Y................ ................. A2............... $127.40 2.4824 $102.77 $121.24
declotting.
36861............ Cannula declotting...... Y................ ................. A2............... $510.00 29.6965 $1,229.46 $689.87
36870............ Percut thrombect av Y................ ................. A2............... $1,339.00 40.4667 $1,675.36 $1,423.09
fistula.
37184............ Prim art mech Y................ ................. G2............... ........... 38.7673 $1,605.00 $1,605.00
thrombectomy.
37185............ Prim art m-thrombect add- Y................ ................. G2............... ........... 38.7673 $1,605.00 $1,605.00
on.
[[Page 66972]]
37186............ Sec art m-thrombect add- Y................ ................. G2............... ........... 38.7673 $1,605.00 $1,605.00
on.
37187............ Venous mech thrombectomy Y................ ................. G2............... ........... 38.7673 $1,605.00 $1,605.00
37188............ Venous m-thrombectomy Y................ ................. G2............... ........... 38.7673 $1,605.00 $1,605.00
add-on.
37200............ Transcatheter biopsy.... Y................ ................. G2............... ........... 28.8743 $1,195.42 $1,195.42
37203............ Transcatheter retrieval. Y................ ................. G2............... ........... 28.8743 $1,195.42 $1,195.42
37250............ Iv us first vessel add- N................ CH............... N1............... ........... ........... ........... ...........
on.
37251............ Iv us each add vessel N................ CH............... N1............... ........... ........... ........... ...........
add-on.
37500............ Endoscopy ligate perf Y................ ................. A2............... $510.00 42.6114 $1,764.15 $823.54
veins.
37607............ Ligation of a-v fistula. Y................ ................. A2............... $510.00 25.841 $1,069.84 $649.96
37609............ Temporal artery Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
procedure.
37650............ Revision of major vein.. Y................ ................. A2............... $446.00 25.841 $1,069.84 $601.96
37700............ Revise leg vein......... Y................ ................. A2............... $446.00 25.841 $1,069.84 $601.96
37718............ Ligate/strip short leg Y................ ................. A2............... $510.00 25.841 $1,069.84 $649.96
vein.
37722............ Ligate/strip long leg Y................ ................. A2............... $510.00 42.6114 $1,764.15 $823.54
vein.
37735............ Removal of leg veins/ Y................ ................. A2............... $510.00 42.6114 $1,764.15 $823.54
lesion.
37760............ Ligation, leg veins, Y................ ................. A2............... $510.00 25.841 $1,069.84 $649.96
open.
37765............ Phleb veins extrem 10-20 Y................ ................. R2............... ........... 25.841 $1,069.84 $1,069.84
37766............ Phleb veins extrem 20+.. Y................ ................. R2............... ........... 25.841 $1,069.84 $1,069.84
37780............ Revision of leg vein.... Y................ ................. A2............... $510.00 25.841 $1,069.84 $649.96
37785............ Ligate/divide/excise Y................ ................. A2............... $510.00 25.841 $1,069.84 $649.96
vein.
37790............ Penile venous occlusion. Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
38200............ Injection for spleen x- N................ ................. N1............... ........... ........... ........... ...........
ray.
38204............ Bl donor search N................ ................. N1............... ........... ........... ........... ...........
management.
38205............ Harvest allogenic stem N................ ................. G2............... ........... 11.5058 $476.35 $476.35
cells.
38206............ Harvest auto stem cells. N................ ................. G2............... ........... 11.5058 $476.35 $476.35
38220............ Bone marrow aspiration.. Y................ CH............... P3............... ........... 2.6333 $109.02 $109.02
38221............ Bone marrow biopsy...... Y................ CH............... P3............... ........... 2.7649 $114.47 $114.47
38230............ Bone marrow collection.. N................ ................. G2............... ........... 30.6035 $1,267.02 $1,267.02
38241............ Bone marrow/stem N................ ................. G2............... ........... 30.6035 $1,267.02 $1,267.02
transplant.
38242............ Lymphocyte infuse N................ ................. R2............... ........... 11.5058 $476.35 $476.35
transplant.
38300............ Drainage, lymph node Y................ ................. A2............... $333.00 11.5594 $478.57 $369.39
lesion.
38305............ Drainage, lymph node Y................ ................. A2............... $446.00 18.3197 $758.45 $524.11
lesion.
38308............ Incision of lymph Y................ ................. A2............... $446.00 22.9584 $950.50 $572.13
channels.
38500............ Biopsy/removal, lymph Y................ ................. A2............... $446.00 22.9584 $950.50 $572.13
nodes.
38505............ Needle biopsy, lymph Y................ ................. A2............... $240.00 7.1147 $294.56 $253.64
nodes.
38510............ Biopsy/removal, lymph Y................ ................. A2............... $446.00 22.9584 $950.50 $572.13
nodes.
38520............ Biopsy/removal, lymph Y................ ................. A2............... $446.00 22.9584 $950.50 $572.13
nodes.
38525............ Biopsy/removal, lymph Y................ ................. A2............... $446.00 22.9584 $950.50 $572.13
nodes.
38530............ Biopsy/removal, lymph Y................ ................. A2............... $446.00 22.9584 $950.50 $572.13
nodes.
38542............ Explore deep node(s), Y................ ................. A2............... $446.00 44.324 $1,835.06 $793.27
neck.
38550............ Removal, neck/armpit Y................ ................. A2............... $510.00 22.9584 $950.50 $620.13
lesion.
38555............ Removal, neck/armpit Y................ ................. A2............... $630.00 22.9584 $950.50 $710.13
lesion.
38570............ Laparoscopy, lymph node Y................ ................. A2............... $1,339.00 45.5317 $1,885.06 $1,475.52
biop.
38571............ Laparoscopy, Y................ ................. A2............... $1,339.00 69.6652 $2,884.21 $1,725.30
lymphadenectomy.
38572............ Laparoscopy, Y................ ................. A2............... $1,339.00 45.5317 $1,885.06 $1,475.52
lymphadenectomy.
38700............ Removal of lymph nodes, Y................ ................. G2............... ........... 22.9584 $950.50 $950.50
neck.
38740............ Remove armpit lymph Y................ ................. A2............... $446.00 44.324 $1,835.06 $793.27
nodes.
38745............ Remove armpit lymph Y................ ................. A2............... $630.00 44.324 $1,835.06 $931.27
nodes.
38760............ Remove groin lymph nodes Y................ ................. A2............... $446.00 22.9584 $950.50 $572.13
38790............ Inject for lymphatic x- N................ ................. N1............... ........... ........... ........... ...........
ray.
38792............ Identify sentinel node.. N................ ................. N1............... ........... ........... ........... ...........
38794............ Access thoracic lymph N................ ................. N1............... ........... ........... ........... ...........
duct.
40490............ Biopsy of lip........... Y................ ................. P3............... ........... 1.5224 $63.03 $63.03
40500............ Partial excision of lip. Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
40510............ Partial excision of lip. Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
40520............ Partial excision of lip. Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
40525............ Reconstruct lip with Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
flap.
40527............ Reconstruct lip with Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
flap.
40530............ Partial removal of lip.. Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
40650............ Repair lip.............. Y................ ................. A2............... $464.15 7.4474 $308.33 $425.20
40652............ Repair lip.............. Y................ ................. A2............... $464.15 7.4474 $308.33 $425.20
40654............ Repair lip.............. Y................ ................. A2............... $464.15 7.4474 $308.33 $425.20
40700............ Repair cleft lip/nasal.. Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
40701............ Repair cleft lip/nasal.. Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
40702............ Repair cleft lip/nasal.. Y................ ................. R2............... ........... 39.8776 $1,650.97 $1,650.97
40720............ Repair cleft lip/nasal.. Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
40761............ Repair cleft lip/nasal.. Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
40800............ Drainage of mouth lesion Y................ ................. P2............... ........... 1.4066 $58.23 $58.23
40801............ Drainage of mouth lesion Y................ ................. A2............... $446.00 7.4474 $308.33 $411.58
40804............ Removal, foreign body, N................ ................. P2............... ........... 0.631 $26.12 $26.12
mouth.
40805............ Removal, foreign body, Y................ ................. P3............... ........... 3.9499 $163.53 $163.53
mouth.
40806............ Incision of lip fold.... Y................ ................. P3............... ........... 1.7529 $72.57 $72.57
40808............ Biopsy of mouth lesion.. Y................ ................. P2............... ........... 2.5002 $103.51 $103.51
[[Page 66973]]
40810............ Excision of mouth lesion Y................ ................. P3............... ........... 2.699 $111.74 $111.74
40812............ Excise/repair mouth Y................ ................. P3............... ........... 3.3985 $140.70 $140.70
lesion.
40814............ Excise/repair mouth Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
lesion.
40816............ Excision of mouth lesion Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
40818............ Excise oral mucosa for Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
graft.
40819............ Excise lip or cheek fold Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
40820............ Treatment of mouth Y................ ................. P3............... ........... 3.7934 $157.05 $157.05
lesion.
40830............ Repair mouth laceration. Y................ ................. G2............... ........... 2.5002 $103.51 $103.51
40831............ Repair mouth laceration. Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
40840............ Reconstruction of mouth. Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
40842............ Reconstruction of mouth. Y................ ................. A2............... $510.00 23.9765 $992.65 $630.66
40843............ Reconstruction of mouth. Y................ ................. A2............... $510.00 23.9765 $992.65 $630.66
40844............ Reconstruction of mouth. Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
40845............ Reconstruction of mouth. Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
41000............ Drainage of mouth lesion Y................ ................. P3............... ........... 1.9997 $82.79 $82.79
41005............ Drainage of mouth lesion Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
41006............ Drainage of mouth lesion Y................ ................. A2............... $333.00 23.9765 $992.65 $497.91
41007............ Drainage of mouth lesion Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
41008............ Drainage of mouth lesion Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
41009............ Drainage of mouth lesion Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
41010............ Incision of tongue fold. Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
41015............ Drainage of mouth lesion Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
41016............ Drainage of mouth lesion Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
41017............ Drainage of mouth lesion Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
41018............ Drainage of mouth lesion Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
41019............ Place needles h&n for rt Y................ NI............... G2............... ........... 23.9765 $992.65 $992.65
41100............ Biopsy of tongue........ Y................ ................. P3............... ........... 2.0983 $86.87 $86.87
41105............ Biopsy of tongue........ Y................ ................. P3............... ........... 2.049 $84.83 $84.83
41108............ Biopsy of floor of mouth Y................ ................. P3............... ........... 1.8927 $78.36 $78.36
41110............ Excision of tongue Y................ ................. P3............... ........... 2.7321 $113.11 $113.11
lesion.
41112............ Excision of tongue Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
lesion.
41113............ Excision of tongue Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
lesion.
41114............ Excision of tongue Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
lesion.
41115............ Excision of tongue fold. Y................ ................. P3............... ........... 3.0777 $127.42 $127.42
41116............ Excision of mouth lesion Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
41120............ Partial removal of Y................ ................. A2............... $717.00 23.9765 $992.65 $785.91
tongue.
41250............ Repair tongue laceration Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
41251............ Repair tongue laceration Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
41252............ Repair tongue laceration Y................ ................. A2............... $446.00 7.4474 $308.33 $411.58
41500............ Fixation of tongue...... Y................ ................. A2............... $333.00 23.9765 $992.65 $497.91
41510............ Tongue to lip surgery... Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
41520............ Reconstruction, tongue Y................ ................. A2............... $446.00 7.4474 $308.33 $411.58
fold.
41800............ Drainage of gum lesion.. Y................ ................. A2............... $88.46 1.4066 $58.23 $80.90
41805............ Removal foreign body, Y................ ................. P3............... ........... 3.0036 $124.35 $124.35
gum.
41806............ Removal foreign Y................ ................. P3............... ........... 3.8675 $160.12 $160.12
body,jawbone.
41820............ Excision, gum, each Y................ ................. R2............... ........... 7.4474 $308.33 $308.33
quadrant.
41821............ Excision of gum flap.... Y................ ................. G2............... ........... 7.4474 $308.33 $308.33
41822............ Excision of gum lesion.. Y................ ................. P3............... ........... 3.5714 $147.86 $147.86
41823............ Excision of gum lesion.. Y................ ................. P3............... ........... 4.9455 $204.75 $204.75
41825............ Excision of gum lesion.. Y................ ................. P3............... ........... 2.7731 $114.81 $114.81
41826............ Excision of gum lesion.. Y................ ................. P3............... ........... 3.0941 $128.10 $128.10
41827............ Excision of gum lesion.. Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
41828............ Excision of gum lesion.. Y................ ................. P3............... ........... 3.2422 $134.23 $134.23
41830............ Removal of gum tissue... Y................ ................. P3............... ........... 4.5011 $186.35 $186.35
41850............ Treatment of gum lesion. Y................ ................. R2............... ........... 16.3288 $676.03 $676.03
41870............ Gum graft............... Y................ ................. G2............... ........... 23.9765 $992.65 $992.65
41872............ Repair gum.............. Y................ ................. P3............... ........... 4.5506 $188.40 $188.40
41874............ Repair tooth socket..... Y................ ................. P3............... ........... 4.3202 $178.86 $178.86
42000............ Drainage mouth roof Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
lesion.
42100............ Biopsy roof of mouth.... Y................ ................. P3............... ........... 1.7939 $74.27 $74.27
42104............ Excision lesion, mouth Y................ ................. P3............... ........... 2.5181 $104.25 $104.25
roof.
42106............ Excision lesion, mouth Y................ ................. P3............... ........... 3.1516 $130.48 $130.48
roof.
42107............ Excision lesion, mouth Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
roof.
42120............ Remove palate/lesion.... Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
42140............ Excision of uvula....... Y................ ................. A2............... $446.00 7.4474 $308.33 $411.58
42145............ Repair palate, pharynx/ Y................ ................. A2............... $717.00 23.9765 $992.65 $785.91
uvula.
42160............ Treatment mouth roof Y................ ................. P3............... ........... 3.2997 $136.61 $136.61
lesion.
42180............ Repair palate........... Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
42182............ Repair palate........... Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
42200............ Reconstruct cleft palate Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
42205............ Reconstruct cleft palate Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
42210............ Reconstruct cleft palate Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
42215............ Reconstruct cleft palate Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
[[Page 66974]]
42220............ Reconstruct cleft palate Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
42226............ Lengthening of palate... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
42235............ Repair palate........... Y................ ................. A2............... $717.00 16.3288 $676.03 $706.76
42260............ Repair nose to lip Y................ ................. A2............... $630.00 23.9765 $992.65 $720.66
fistula.
42280............ Preparation, palate mold Y................ ................. P3............... ........... 1.728 $71.54 $71.54
42281............ Insertion, palate Y................ ................. G2............... ........... 16.3288 $676.03 $676.03
prosthesis.
42300............ Drainage of salivary Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
gland.
42305............ Drainage of salivary Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
gland.
42310............ Drainage of salivary Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
gland.
42320............ Drainage of salivary Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
gland.
42330............ Removal of salivary Y................ ................. P3............... ........... 2.6908 $111.40 $111.40
stone.
42335............ Removal of salivary Y................ ................. P3............... ........... 4.3859 $181.58 $181.58
stone.
42340............ Removal of salivary Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
stone.
42400............ Biopsy of salivary gland Y................ ................. P3............... ........... 1.4975 $62.00 $62.00
42405............ Biopsy of salivary gland Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
42408............ Excision of salivary Y................ ................. A2............... $510.00 16.3288 $676.03 $551.51
cyst.
42409............ Drainage of salivary Y................ ................. A2............... $510.00 16.3288 $676.03 $551.51
cyst.
42410............ Excise parotid gland/ Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
lesion.
42415............ Excise parotid gland/ Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
lesion.
42420............ Excise parotid gland/ Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
lesion.
42425............ Excise parotid gland/ Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
lesion.
42440............ Excise submaxillary Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
gland.
42450............ Excise sublingual gland. Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
42500............ Repair salivary duct.... Y................ ................. A2............... $510.00 23.9765 $992.65 $630.66
42505............ Repair salivary duct.... Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
42507............ Parotid duct diversion.. Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
42508............ Parotid duct diversion.. Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
42509............ Parotid duct diversion.. Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
42510............ Parotid duct diversion.. Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
42550............ Injection for salivary x- N................ ................. N1............... ........... ........... ........... ...........
ray.
42600............ Closure of salivary Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
fistula.
42650............ Dilation of salivary Y................ ................. P3............... ........... 0.9792 $40.54 $40.54
duct.
42660............ Dilation of salivary Y................ ................. P3............... ........... 1.1521 $47.70 $47.70
duct.
42665............ Ligation of salivary Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
duct.
42700............ Drainage of tonsil Y................ ................. A2............... $150.72 2.5002 $103.51 $138.92
abscess.
42720............ Drainage of throat Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
abscess.
42725............ Drainage of throat Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
abscess.
42800............ Biopsy of throat........ Y................ ................. P3............... ........... 1.9091 $79.04 $79.04
42802............ Biopsy of throat........ Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
42804............ Biopsy of upper nose/ Y................ ................. A2............... $333.00 16.3288 $676.03 $418.76
throat.
42806............ Biopsy of upper nose/ Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
throat.
42808............ Excise pharynx lesion... Y................ ................. A2............... $446.00 16.3288 $676.03 $503.51
42809............ Remove pharynx foreign N................ ................. G2............... ........... 0.631 $26.12 $26.12
body.
42810............ Excision of neck cyst... Y................ ................. A2............... $510.00 23.9765 $992.65 $630.66
42815............ Excision of neck cyst... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
42820............ Remove tonsils and Y................ ................. A2............... $510.00 22.2557 $921.41 $612.85
adenoids.
42821............ Remove tonsils and Y................ ................. A2............... $717.00 22.2557 $921.41 $768.10
adenoids.
42825............ Removal of tonsils...... Y................ ................. A2............... $630.00 22.2557 $921.41 $702.85
42826............ Removal of tonsils...... Y................ ................. A2............... $630.00 22.2557 $921.41 $702.85
42830............ Removal of adenoids..... Y................ ................. A2............... $630.00 22.2557 $921.41 $702.85
42831............ Removal of adenoids..... Y................ ................. A2............... $630.00 22.2557 $921.41 $702.85
42835............ Removal of adenoids..... Y................ ................. A2............... $630.00 22.2557 $921.41 $702.85
42836............ Removal of adenoids..... Y................ ................. A2............... $630.00 22.2557 $921.41 $702.85
42860............ Excision of tonsil tags. Y................ ................. A2............... $510.00 22.2557 $921.41 $612.85
42870............ Excision of lingual Y................ ................. A2............... $510.00 22.2557 $921.41 $612.85
tonsil.
42890............ Partial removal of Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
pharynx.
42892............ Revision of pharyngeal Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
walls.
42900............ Repair throat wound..... Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
42950............ Reconstruction of throat Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
42955............ Surgical opening of Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
throat.
42960............ Control throat bleeding. Y................ ................. A2............... $72.48 1.1251 $46.58 $66.01
42962............ Control throat bleeding. Y................ ................. A2............... $446.00 39.8776 $1,650.97 $747.24
42970............ Control nose/throat Y................ ................. R2............... ........... 1.1251 $46.58 $46.58
bleeding.
42972............ Control nose/throat Y................ ................. A2............... $510.00 16.3288 $676.03 $551.51
bleeding.
43030............ Throat muscle surgery... Y................ ................. G2............... ........... 16.3288 $676.03 $676.03
43200............ Esophagus endoscopy..... Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
43201............ Esoph scope w/submucous Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
inj.
43202............ Esophagus endoscopy, Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
biopsy.
43204............ Esoph scope w/sclerosis Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
inj.
43205............ Esophagus endoscopy/ Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
ligation.
43215............ Esophagus endoscopy..... Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
43216............ Esophagus endoscopy/ Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
lesion.
43217............ Esophagus endoscopy..... Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
[[Page 66975]]
43219............ Esophagus endoscopy..... Y................ ................. A2............... $333.00 24.9814 $1,034.25 $508.31
43220............ Esoph endoscopy, Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
dilation.
43226............ Esoph endoscopy, Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
dilation.
43227............ Esoph endoscopy, repair. Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
43228............ Esoph endoscopy, Y................ ................. A2............... $446.00 25.3233 $1,048.41 $596.60
ablation.
43231............ Esoph endoscopy w/us Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
exam.
43232............ Esoph endoscopy w/us fn Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
bx.
43234............ Upper gi endoscopy, exam Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
43235............ Uppr gi endoscopy, Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
diagnosis.
43236............ Uppr gi scope w/submuc Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
inj.
43237............ Endoscopic us exam, Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
esoph.
43238............ Uppr gi endoscopy w/us Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
fn bx.
43239............ Upper gi endoscopy, Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
biopsy.
43240............ Esoph endoscope w/drain Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
cyst.
43241............ Upper gi endoscopy with Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
tube.
43242............ Uppr gi endoscopy w/us Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
fn bx.
43243............ Upper gi endoscopy & Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
inject.
43244............ Upper gi endoscopy/ Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
ligation.
43245............ Uppr gi scope dilate Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
strictr.
43246............ Place gastrostomy tube.. Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
43247............ Operative upper gi Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
endoscopy.
43248............ Uppr gi endoscopy/guide Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
wire.
43249............ Esoph endoscopy, Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
dilation.
43250............ Upper gi endoscopy/tumor Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
43251............ Operative upper gi Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
endoscopy.
43255............ Operative upper gi Y................ ................. A2............... $446.00 8.503 $352.03 $422.51
endoscopy.
43256............ Uppr gi endoscopy w/ Y................ ................. A2............... $510.00 24.9814 $1,034.25 $641.06
stent.
43257............ Uppr gi scope w/thrml Y................ ................. A2............... $510.00 25.3233 $1,048.41 $644.60
txmnt.
43258............ Operative upper gi Y................ ................. A2............... $510.00 8.503 $352.03 $470.51
endoscopy.
43259............ Endoscopic ultrasound Y................ ................. A2............... $510.00 8.503 $352.03 $470.51
exam.
43260............ Endo Y................ ................. A2............... $446.00 20.951 $867.39 $551.35
cholangiopancreatograph.
43261............ Endo Y................ ................. A2............... $446.00 20.951 $867.39 $551.35
cholangiopancreatograph.
43262............ Endo Y................ ................. A2............... $446.00 20.951 $867.39 $551.35
cholangiopancreatograph.
43263............ Endo Y................ ................. A2............... $446.00 20.951 $867.39 $551.35
cholangiopancreatograph.
43264............ Endo Y................ ................. A2............... $446.00 20.951 $867.39 $551.35
cholangiopancreatograph.
43265............ Endo Y................ ................. A2............... $446.00 20.951 $867.39 $551.35
cholangiopancreatograph.
43267............ Endo Y................ ................. A2............... $446.00 20.951 $867.39 $551.35
cholangiopancreatograph.
43268............ Endo Y................ ................. A2............... $446.00 24.9814 $1,034.25 $593.06
cholangiopancreatograph.
43269............ Endo Y................ ................. A2............... $446.00 24.9814 $1,034.25 $593.06
cholangiopancreatograph.
43271............ Endo Y................ ................. A2............... $446.00 20.951 $867.39 $551.35
cholangiopancreatograph.
43272............ Endo Y................ ................. A2............... $446.00 20.951 $867.39 $551.35
cholangiopancreatograph.
43450............ Dilate esophagus........ Y................ ................. A2............... $333.00 5.8431 $241.91 $310.23
43453............ Dilate esophagus........ Y................ ................. A2............... $333.00 5.8431 $241.91 $310.23
43456............ Dilate esophagus........ Y................ ................. A2............... $335.41 5.8431 $241.91 $312.04
43458............ Dilate esophagus........ Y................ ................. A2............... $335.41 8.503 $352.03 $339.57
43600............ Biopsy of stomach....... Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
43653............ Laparoscopy, gastrostomy Y................ ................. A2............... $1,339.00 45.5317 $1,885.06 $1,475.52
43750............ Place gastrostomy tube.. N................ CH............... D5............... ........... ........... ........... ...........
43760............ Change gastrostomy tube. Y................ ................. A2............... $144.98 3.2383 $134.07 $142.25
43761............ Reposition gastrostomy Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
tube.
43870............ Repair stomach opening.. Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
43886............ Revise gastric port, Y................ ................. G2............... ........... 20.2069 $836.59 $836.59
open.
43887............ Remove gastric port, Y................ ................. G2............... ........... 4.5263 $187.39 $187.39
open.
43888............ Change gastric port, Y................ ................. G2............... ........... 20.2069 $836.59 $836.59
open.
44100............ Biopsy of bowel......... Y................ ................. A2............... $333.00 8.503 $352.03 $337.76
44312............ Revision of ileostomy... Y................ ................. A2............... $333.00 20.2069 $836.59 $458.90
44340............ Revision of colostomy... Y................ ................. A2............... $510.00 20.2069 $836.59 $591.65
44360............ Small bowel endoscopy... Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
44361............ Small bowel endoscopy/ Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
biopsy.
44363............ Small bowel endoscopy... Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
44364............ Small bowel endoscopy... Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
44365............ Small bowel endoscopy... Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
44366............ Small bowel endoscopy... Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
44369............ Small bowel endoscopy... Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
44370............ Small bowel endoscopy/ Y................ ................. A2............... $1,339.00 24.9814 $1,034.25 $1,262.81
stent.
44372............ Small bowel endoscopy... Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
44373............ Small bowel endoscopy... Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
44376............ Small bowel endoscopy... Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
44377............ Small bowel endoscopy/ Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
biopsy.
44378............ Small bowel endoscopy... Y................ ................. A2............... $446.00 9.5292 $394.52 $433.13
44379............ S bowel endoscope w/ Y................ ................. A2............... $1,339.00 24.9814 $1,034.25 $1,262.81
stent.
44380............ Small bowel endoscopy... Y................ ................. A2............... $333.00 9.5292 $394.52 $348.38
44382............ Small bowel endoscopy... Y................ ................. A2............... $333.00 9.5292 $394.52 $348.38
[[Page 66976]]
44383............ Ileoscopy w/stent....... Y................ ................. A2............... $1,339.00 24.9814 $1,034.25 $1,262.81
44385............ Endoscopy of bowel pouch Y................ ................. A2............... $333.00 8.8486 $366.34 $341.34
44386............ Endoscopy, bowel pouch/ Y................ ................. A2............... $333.00 8.8486 $366.34 $341.34
biop.
44388............ Colonoscopy............. Y................ ................. A2............... $333.00 8.8486 $366.34 $341.34
44389............ Colonoscopy with biopsy. Y................ ................. A2............... $333.00 8.8486 $366.34 $341.34
44390............ Colonoscopy for foreign Y................ ................. A2............... $333.00 8.8486 $366.34 $341.34
body.
44391............ Colonoscopy for bleeding Y................ ................. A2............... $333.00 8.8486 $366.34 $341.34
44392............ Colonoscopy & Y................ ................. A2............... $333.00 8.8486 $366.34 $341.34
polypectomy.
44393............ Colonoscopy, lesion Y................ ................. A2............... $333.00 8.8486 $366.34 $341.34
removal.
44394............ Colonoscopy w/snare..... Y................ ................. A2............... $333.00 8.8486 $366.34 $341.34
44397............ Colonoscopy w/stent..... Y................ ................. A2............... $333.00 24.9814 $1,034.25 $508.31
44500............ Intro, gastrointestinal Y................ CH............... G2............... ........... 3.2383 $134.07 $134.07
tube.
44701............ Intraop colon lavage add- N................ ................. N1............... ........... ........... ........... ...........
on.
45000............ Drainage of pelvic Y................ ................. A2............... $312.07 10.9132 $451.82 $347.01
abscess.
45005............ Drainage of rectal Y................ ................. A2............... $446.00 10.9132 $451.82 $447.46
abscess.
45020............ Drainage of rectal Y................ ................. A2............... $446.00 10.9132 $451.82 $447.46
abscess.
45100............ Biopsy of rectum........ Y................ ................. A2............... $333.00 22.7451 $941.67 $485.17
45108............ Removal of anorectal Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
lesion.
45150............ Excision of rectal Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
stricture.
45160............ Excision of rectal Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
lesion.
45170............ Excision of rectal Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
lesion.
45190............ Destruction, rectal Y................ ................. A2............... $1,339.00 22.7451 $941.67 $1,239.67
tumor.
45300............ Proctosigmoidoscopy dx.. Y................ ................. P3............... ........... 1.4318 $59.28 $59.28
45303............ Proctosigmoidoscopy Y................ ................. P2............... ........... 8.7031 $360.32 $360.32
dilate.
45305............ Proctosigmoidoscopy w/bx Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
45307............ Proctosigmoidoscopy fb.. Y................ ................. A2............... $333.00 21.4632 $888.60 $471.90
45308............ Proctosigmoidoscopy Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
removal.
45309............ Proctosigmoidoscopy Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
removal.
45315............ Proctosigmoidoscopy Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
removal.
45317............ Proctosigmoidoscopy Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
bleed.
45320............ Proctosigmoidoscopy Y................ ................. A2............... $333.00 21.4632 $888.60 $471.90
ablate.
45321............ Proctosigmoidoscopy Y................ ................. A2............... $333.00 21.4632 $888.60 $471.90
volvul.
45327............ Proctosigmoidoscopy w/ Y................ ................. A2............... $333.00 24.9814 $1,034.25 $508.31
stent.
45330............ Diagnostic sigmoidoscopy Y................ ................. P3............... ........... 1.9748 $81.76 $81.76
45331............ Sigmoidoscopy and biopsy Y................ ................. A2............... $299.24 5.0972 $211.03 $277.19
45332............ Sigmoidoscopy w/fb Y................ ................. A2............... $299.24 5.0972 $211.03 $277.19
removal.
45333............ Sigmoidoscopy & Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
polypectomy.
45334............ Sigmoidoscopy for Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
bleeding.
45335............ Sigmoidoscopy w/submuc Y................ ................. A2............... $299.24 5.0972 $211.03 $277.19
inj.
45337............ Sigmoidoscopy & Y................ ................. A2............... $299.24 5.0972 $211.03 $277.19
decompress.
45338............ Sigmoidoscopy w/tumr Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
remove.
45339............ Sigmoidoscopy w/ablate Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
tumr.
45340............ Sig w/balloon dilation.. Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
45341............ Sigmoidoscopy w/ Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
ultrasound.
45342............ Sigmoidoscopy w/us guide Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
bx.
45345............ Sigmoidoscopy w/stent... Y................ ................. A2............... $333.00 24.9814 $1,034.25 $508.31
45355............ Surgical colonoscopy.... Y................ ................. A2............... $333.00 8.8486 $366.34 $341.34
45378............ Diagnostic colonoscopy.. Y................ ................. A2............... $446.00 8.8486 $366.34 $426.09
45379............ Colonoscopy w/fb removal Y................ ................. A2............... $446.00 8.8486 $366.34 $426.09
45380............ Colonoscopy and biopsy.. Y................ ................. A2............... $446.00 8.8486 $366.34 $426.09
45381............ Colonoscopy, submucous Y................ ................. A2............... $446.00 8.8486 $366.34 $426.09
inj.
45382............ Colonoscopy/control Y................ ................. A2............... $446.00 8.8486 $366.34 $426.09
bleeding.
45383............ Lesion removal Y................ ................. A2............... $446.00 8.8486 $366.34 $426.09
colonoscopy.
45384............ Lesion remove Y................ ................. A2............... $446.00 8.8486 $366.34 $426.09
colonoscopy.
45385............ Lesion removal Y................ ................. A2............... $446.00 8.8486 $366.34 $426.09
colonoscopy.
45386............ Colonoscopy dilate Y................ ................. A2............... $446.00 8.8486 $366.34 $426.09
stricture.
45387............ Colonoscopy w/stent..... Y................ ................. A2............... $333.00 24.9814 $1,034.25 $508.31
45391............ Colonoscopy w/endoscope Y................ ................. A2............... $446.00 8.8486 $366.34 $426.09
us.
45392............ Colonoscopy w/endoscopic Y................ ................. A2............... $446.00 8.8486 $366.34 $426.09
fnb.
45500............ Repair of rectum........ Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
45505............ Repair of rectum........ Y................ ................. A2............... $446.00 30.1606 $1,248.68 $646.67
45520............ Treatment of rectal Y................ ................. P2............... ........... 0.793 $32.83 $32.83
prolapse.
45560............ Repair of rectocele..... Y................ ................. A2............... $446.00 30.1606 $1,248.68 $646.67
45900............ Reduction of rectal Y................ ................. A2............... $312.07 4.7935 $198.46 $283.67
prolapse.
45905............ Dilation of anal Y................ ................. A2............... $333.00 22.7451 $941.67 $485.17
sphincter.
45910............ Dilation of rectal Y................ ................. A2............... $333.00 22.7451 $941.67 $485.17
narrowing.
45915............ Remove rectal Y................ ................. A2............... $312.07 10.9132 $451.82 $347.01
obstruction.
45990............ Surg dx exam, anorectal. Y................ ................. A2............... $312.07 22.7451 $941.67 $469.47
46020............ Placement of seton...... Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
46030............ Removal of rectal marker Y................ ................. A2............... $312.07 4.7935 $198.46 $283.67
46040............ Incision of rectal Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
abscess.
46045............ Incision of rectal Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
abscess.
46050............ Incision of anal abscess Y................ ................. A2............... $312.07 10.9132 $451.82 $347.01
[[Page 66977]]
46060............ Incision of rectal Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
abscess.
46070............ Incision of anal septum. Y................ ................. G2............... ........... 10.9132 $451.82 $451.82
46080............ Incision of anal Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
sphincter.
46083............ Incise external Y................ ................. P3............... ........... 2.0079 $83.13 $83.13
hemorrhoid.
46200............ Removal of anal fissure. Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
46210............ Removal of anal crypt... Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
46211............ Removal of anal crypts.. Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
46220............ Removal of anal tag..... Y................ ................. A2............... $333.00 22.7451 $941.67 $485.17
46221............ Ligation of Y................ ................. P3............... ........... 2.6251 $108.68 $108.68
hemorrhoid(s).
46230............ Removal of anal tags.... Y................ ................. A2............... $333.00 22.7451 $941.67 $485.17
46250............ Hemorrhoidectomy........ Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
46255............ Hemorrhoidectomy........ Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
46257............ Remove hemorrhoids & Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
fissure.
46258............ Remove hemorrhoids & Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
fistula.
46260............ Hemorrhoidectomy........ Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
46261............ Remove hemorrhoids & Y................ ................. A2............... $630.00 22.7451 $941.67 $707.92
fissure.
46262............ Remove hemorrhoids & Y................ ................. A2............... $630.00 22.7451 $941.67 $707.92
fistula.
46270............ Removal of anal fistula. Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
46275............ Removal of anal fistula. Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
46280............ Removal of anal fistula. Y................ ................. A2............... $630.00 22.7451 $941.67 $707.92
46285............ Removal of anal fistula. Y................ ................. A2............... $333.00 22.7451 $941.67 $485.17
46288............ Repair anal fistula..... Y................ ................. A2............... $630.00 22.7451 $941.67 $707.92
46320............ Removal of hemorrhoid Y................ ................. P3............... ........... 1.8596 $76.99 $76.99
clot.
46500............ Injection into Y................ ................. P3............... ........... 2.3536 $97.44 $97.44
hemorrhoid(s).
46505............ Chemodenervation anal Y................ ................. G2............... ........... 4.7935 $198.46 $198.46
musc.
46600............ Diagnostic anoscopy..... N................ ................. P2............... ........... 0.631 $26.12 $26.12
46604............ Anoscopy and dilation... Y................ ................. P2............... ........... 8.7031 $360.32 $360.32
46606............ Anoscopy and biopsy..... Y................ ................. P3............... ........... 3.1434 $130.14 $130.14
46608............ Anoscopy, remove for Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
body.
46610............ Anoscopy, remove lesion. Y................ ................. A2............... $333.00 21.4632 $888.60 $471.90
46611............ Anoscopy................ Y................ ................. A2............... $333.00 8.7031 $360.32 $339.83
46612............ Anoscopy, remove lesions Y................ ................. A2............... $333.00 21.4632 $888.60 $471.90
46614............ Anoscopy, control Y................ ................. P3............... ........... 1.7529 $72.57 $72.57
bleeding.
46615............ Anoscopy................ Y................ ................. A2............... $446.00 21.4632 $888.60 $556.65
46700............ Repair of anal stricture Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
46706............ Repr of anal fistula w/ Y................ ................. A2............... $333.00 30.1606 $1,248.68 $561.92
glue.
46750............ Repair of anal sphincter Y................ ................. A2............... $510.00 30.1606 $1,248.68 $694.67
46753............ Reconstruction of anus.. Y................ ................. A2............... $510.00 22.7451 $941.67 $617.92
46754............ Removal of suture from Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
anus.
46760............ Repair of anal sphincter Y................ ................. A2............... $446.00 30.1606 $1,248.68 $646.67
46761............ Repair of anal sphincter Y................ ................. A2............... $510.00 30.1606 $1,248.68 $694.67
46762............ Implant artificial Y................ ................. A2............... $995.00 30.1606 $1,248.68 $1,058.42
sphincter.
46900............ Destruction, anal Y................ ................. P3............... ........... 2.5673 $106.29 $106.29
lesion(s).
46910............ Destruction, anal Y................ ................. P3............... ........... 2.7895 $115.49 $115.49
lesion(s).
46916............ Cryosurgery, anal Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
lesion(s).
46917............ Laser surgery, anal Y................ ................. A2............... $333.00 19.9041 $824.05 $455.76
lesions.
46922............ Excision of anal Y................ ................. A2............... $333.00 19.9041 $824.05 $455.76
lesion(s).
46924............ Destruction, anal Y................ ................. A2............... $333.00 19.9041 $824.05 $455.76
lesion(s).
46934............ Destruction of Y................ ................. P3............... ........... 4.3695 $180.90 $180.90
hemorrhoids.
46935............ Destruction of Y................ ................. P3............... ........... 3.0118 $124.69 $124.69
hemorrhoids.
46936............ Destruction of Y................ ................. P3............... ........... 4.567 $189.08 $189.08
hemorrhoids.
46937............ Cryotherapy of rectal Y................ ................. A2............... $446.00 22.7451 $941.67 $569.92
lesion.
46938............ Cryotherapy of rectal Y................ ................. A2............... $446.00 30.1606 $1,248.68 $646.67
lesion.
46940............ Treatment of anal Y................ ................. P3............... ........... 1.9915 $82.45 $82.45
fissure.
46942............ Treatment of anal Y................ ................. P3............... ........... 1.9091 $79.04 $79.04
fissure.
46945............ Ligation of hemorrhoids. Y................ ................. P3............... ........... 3.3161 $137.29 $137.29
46946............ Ligation of hemorrhoids. Y................ ................. A2............... $333.00 10.9132 $451.82 $362.71
46947............ Hemorrhoidopexy by Y................ ................. A2............... $995.00 30.1606 $1,248.68 $1,058.42
stapling.
47000............ Needle biopsy of liver.. Y................ ................. A2............... $333.00 9.3354 $386.49 $346.37
47001............ Needle biopsy, liver add- N................ ................. N1............... ........... ........... ........... ...........
on.
47382............ Percut ablate liver rf.. Y................ ................. G2............... ........... 42.998 $1,780.16 $1,780.16
47500............ Injection for liver x- N................ ................. N1............... ........... ........... ........... ...........
rays.
47505............ Injection for liver x- N................ ................. N1............... ........... ........... ........... ...........
rays.
47510............ Insert catheter, bile Y................ ................. A2............... $446.00 28.6884 $1,187.73 $631.43
duct.
47511............ Insert bile duct drain.. Y................ ................. A2............... $1,245.85 28.6884 $1,187.73 $1,231.32
47525............ Change bile duct Y................ ................. A2............... $333.00 15.3545 $635.69 $408.67
catheter.
47530............ Revise/reinsert bile Y................ ................. A2............... $333.00 15.3545 $635.69 $408.67
tube.
47552............ Biliary endoscopy thru Y................ ................. A2............... $446.00 28.6884 $1,187.73 $631.43
skin.
47553............ Biliary endoscopy thru Y................ ................. A2............... $510.00 28.6884 $1,187.73 $679.43
skin.
47554............ Biliary endoscopy thru Y................ ................. A2............... $510.00 28.6884 $1,187.73 $679.43
skin.
47555............ Biliary endoscopy thru Y................ ................. A2............... $510.00 28.6884 $1,187.73 $679.43
skin.
47556............ Biliary endoscopy thru Y................ ................. A2............... $1,245.85 28.6884 $1,187.73 $1,231.32
skin.
47560............ Laparoscopy w/cholangio. Y................ ................. A2............... $510.00 34.3958 $1,424.02 $738.51
[[Page 66978]]
47561............ Laparo w/cholangio/ Y................ ................. A2............... $510.00 34.3958 $1,424.02 $738.51
biopsy.
47562............ Laparoscopic Y................ ................. G2............... ........... 45.5317 $1,885.06 $1,885.06
cholecystectomy.
47563............ Laparo cholecystectomy/ Y................ ................. G2............... ........... 45.5317 $1,885.06 $1,885.06
graph.
47564............ Laparo cholecystectomy/ Y................ ................. G2............... ........... 45.5317 $1,885.06 $1,885.06
explr.
47630............ Remove bile duct stone.. Y................ ................. A2............... $510.00 28.6884 $1,187.73 $679.43
48102............ Needle biopsy, pancreas. Y................ ................. A2............... $333.00 9.3354 $386.49 $346.37
49080............ Puncture, peritoneal Y................ ................. A2............... $222.78 5.2024 $215.38 $220.93
cavity.
49081............ Removal of abdominal Y................ ................. A2............... $222.78 5.2024 $215.38 $220.93
fluid.
49180............ Biopsy, abdominal mass.. Y................ ................. A2............... $333.00 9.3354 $386.49 $346.37
49250............ Excision of umbilicus... Y................ ................. A2............... $630.00 25.6947 $1,063.79 $738.45
49320............ Diag laparo separate Y................ ................. A2............... $510.00 34.3958 $1,424.02 $738.51
proc.
49321............ Laparoscopy, biopsy..... Y................ ................. A2............... $630.00 34.3958 $1,424.02 $828.51
49322............ Laparoscopy, aspiration. Y................ ................. A2............... $630.00 34.3958 $1,424.02 $828.51
49400............ Air injection into N................ ................. N1............... ........... ........... ........... ...........
abdomen.
49402............ Remove foreign body, Y................ ................. A2............... $446.00 25.6947 $1,063.79 $600.45
adbomen.
49419............ Insrt abdom cath for Y................ ................. A2............... $333.00 29.6965 $1,229.46 $557.12
chemotx.
49420............ Insert abdom drain, temp Y................ ................. A2............... $333.00 30.7096 $1,271.41 $567.60
49421............ Insert abdom drain, perm Y................ ................. A2............... $333.00 30.7096 $1,271.41 $567.60
49422............ Remove perm cannula/ Y................ ................. A2............... $333.00 23.9802 $992.80 $497.95
catheter.
49423............ Exchange drainage Y................ ................. G2............... ........... 15.3545 $635.69 $635.69
catheter.
49424............ Assess cyst, contrast N................ ................. N1............... ........... ........... ........... ...........
inject.
49426............ Revise abdomen-venous Y................ ................. A2............... $446.00 25.6947 $1,063.79 $600.45
shunt.
49427............ Injection, abdominal N................ ................. N1............... ........... ........... ........... ...........
shunt.
49429............ Removal of shunt........ Y................ ................. G2............... ........... 23.9802 $992.80 $992.80
49440............ Place gastrostomy tube Y................ NI............... G2............... ........... 8.503 $352.03 $352.03
perc.
49441............ Place duod/jej tube perc Y................ NI............... G2............... ........... 8.503 $352.03 $352.03
49446............ Change g-tube to g-j Y................ NI............... G2............... ........... 8.503 $352.03 $352.03
perc.
49450............ Replace g/c tube perc... Y................ NI............... G2............... ........... 3.2383 $134.07 $134.07
49451............ Replace duod/jej tube Y................ NI............... G2............... ........... 3.2383 $134.07 $134.07
perc.
49452............ Replace g-j tube perc... Y................ NI............... G2............... ........... 3.2383 $134.07 $134.07
49460............ Fix g/colon tube w/ Y................ NI............... G2............... ........... 3.2383 $134.07 $134.07
device.
49465............ Fluoro exam of g/colon N................ NI............... N1............... ........... ........... ........... ...........
tube.
49495............ Rpr ing hernia baby, Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
reduc.
49496............ Rpr ing hernia baby, Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
blocked.
49500............ Rpr ing hernia, init, Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
reduce.
49501............ Rpr ing hernia, init Y................ ................. A2............... $1,339.00 30.6788 $1,270.13 $1,321.78
blocked.
49505............ Prp i/hern init reduc >5 Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
yr.
49507............ Prp i/hern init block >5 Y................ ................. A2............... $1,339.00 30.6788 $1,270.13 $1,321.78
yr.
49520............ Rerepair ing hernia, Y................ ................. A2............... $995.00 30.6788 $1,270.13 $1,063.78
reduce.
49521............ Rerepair ing hernia, Y................ ................. A2............... $1,339.00 30.6788 $1,270.13 $1,321.78
blocked.
49525............ Repair ing hernia, Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
sliding.
49540............ Repair lumbar hernia.... Y................ ................. A2............... $446.00 30.6788 $1,270.13 $652.03
49550............ Rpr rem hernia, init, Y................ ................. A2............... $717.00 30.6788 $1,270.13 $855.28
reduce.
49553............ Rpr fem hernia, init Y................ ................. A2............... $1,339.00 30.6788 $1,270.13 $1,321.78
blocked.
49555............ Rerepair fem hernia, Y................ ................. A2............... $717.00 30.6788 $1,270.13 $855.28
reduce.
49557............ Rerepair fem hernia, Y................ ................. A2............... $1,339.00 30.6788 $1,270.13 $1,321.78
blocked.
49560............ Rpr ventral hern init, Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
reduc.
49561............ Rpr ventral hern init, Y................ ................. A2............... $1,339.00 30.6788 $1,270.13 $1,321.78
block.
49565............ Rerepair ventrl hern, Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
reduce.
49566............ Rerepair ventrl hern, Y................ ................. A2............... $1,339.00 30.6788 $1,270.13 $1,321.78
block.
49568............ Hernia repair w/mesh.... Y................ ................. A2............... $995.00 30.6788 $1,270.13 $1,063.78
49570............ Rpr epigastric hern, Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
reduce.
49572............ Rpr epigastric hern, Y................ ................. A2............... $1,339.00 30.6788 $1,270.13 $1,321.78
blocked.
49580............ Rpr umbil hern, reduc < Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
5 yr.
49582............ Rpr umbil hern, block < Y................ ................. A2............... $1,339.00 30.6788 $1,270.13 $1,321.78
5 yr.
49585............ Rpr umbil hern, reduc > Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
5 yr.
49587............ Rpr umbil hern, block > Y................ ................. A2............... $1,339.00 30.6788 $1,270.13 $1,321.78
5 yr.
49590............ Repair spigelian hernia. Y................ ................. A2............... $510.00 30.6788 $1,270.13 $700.03
49600............ Repair umbilical lesion. Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
49650............ Laparo hernia repair Y................ ................. A2............... $630.00 45.5317 $1,885.06 $943.77
initial.
49651............ Laparo hernia repair Y................ ................. A2............... $995.00 45.5317 $1,885.06 $1,217.52
recur.
50200............ Biopsy of kidney........ Y................ ................. A2............... $333.00 9.3354 $386.49 $346.37
50382............ Change ureter stent, Y................ ................. G2............... ........... 24.7749 $1,025.71 $1,025.71
percut.
50384............ Remove ureter stent, Y................ ................. G2............... ........... 17.942 $742.82 $742.82
percut.
50385............ Change stent via Y................ NI............... G2............... ........... 17.942 $742.82 $742.82
transureth.
50386............ Remove stent via Y................ NI............... G2............... ........... 5.9735 $247.31 $247.31
transureth.
50387............ Change ext/int ureter Y................ ................. G2............... ........... 15.3545 $635.69 $635.69
stent.
50389............ Remove renal tube w/ Y................ ................. G2............... ........... 5.9735 $247.31 $247.31
fluoro.
50390............ Drainage of kidney Y................ ................. A2............... $333.00 9.3354 $386.49 $346.37
lesion.
50391............ Instll rx agnt into rnal Y................ ................. P2............... ........... 1.0356 $42.87 $42.87
tub.
50392............ Insert kidney drain..... Y................ ................. A2............... $333.00 17.942 $742.82 $435.46
50393............ Insert ureteral tube.... Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
50394............ Injection for kidney x- N................ ................. N1............... ........... ........... ........... ...........
ray.
[[Page 66979]]
50395............ Create passage to kidney Y................ ................. A2............... $333.00 17.942 $742.82 $435.46
50396............ Measure kidney pressure. Y................ ................. A2............... $131.50 2.0077 $83.12 $119.41
50398............ Change kidney tube...... Y................ ................. A2............... $333.00 15.3545 $635.69 $408.67
50551............ Kidney endoscopy........ Y................ ................. A2............... $333.00 5.9735 $247.31 $311.58
50553............ Kidney endoscopy........ Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
50555............ Kidney endoscopy & Y................ ................. A2............... $333.00 5.9735 $247.31 $311.58
biopsy.
50557............ Kidney endoscopy & Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
treatment.
50561............ Kidney endoscopy & Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
treatment.
50562............ Renal scope w/tumor Y................ ................. G2............... ........... 5.9735 $247.31 $247.31
resect.
50570............ Kidney endoscopy........ Y................ ................. G2............... ........... 5.9735 $247.31 $247.31
50572............ Kidney endoscopy........ Y................ ................. G2............... ........... 5.9735 $247.31 $247.31
50574............ Kidney endoscopy & Y................ ................. G2............... ........... 5.9735 $247.31 $247.31
biopsy.
50575............ Kidney endoscopy........ Y................ ................. G2............... ........... 36.0774 $1,493.64 $1,493.64
50576............ Kidney endoscopy & Y................ ................. G2............... ........... 17.942 $742.82 $742.82
treatment.
50580............ Kidney endoscopy & Y................ CH............... G2............... ........... 17.942 $742.82 $742.82
treatment.
50590............ Fragmenting of kidney Y................ ................. G2............... ........... 41.5299 $1,719.38 $1,719.38
stone.
50592............ Perc rf ablate renal Y................ ................. G2............... ........... 42.998 $1,780.16 $1,780.16
tumor.
50684............ Injection for ureter x- N................ ................. N1............... ........... ........... ........... ...........
ray.
50686............ Measure ureter pressure. Y................ ................. P2............... ........... 1.0356 $42.87 $42.87
50688............ Change of ureter tube/ Y................ ................. A2............... $333.00 15.3545 $635.69 $408.67
stent.
50690............ Injection for ureter x- N................ ................. N1............... ........... ........... ........... ...........
ray.
50947............ Laparo new ureter/ Y................ ................. A2............... $1,339.00 45.5317 $1,885.06 $1,475.52
bladder.
50948............ Laparo new ureter/ Y................ ................. A2............... $1,339.00 45.5317 $1,885.06 $1,475.52
bladder.
50951............ Endoscopy of ureter..... Y................ ................. A2............... $333.00 5.9735 $247.31 $311.58
50953............ Endoscopy of ureter..... Y................ ................. A2............... $333.00 5.9735 $247.31 $311.58
50955............ Ureter endoscopy & Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
biopsy.
50957............ Ureter endoscopy & Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
treatment.
50961............ Ureter endoscopy & Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
treatment.
50970............ Ureter endoscopy........ Y................ ................. A2............... $333.00 5.9735 $247.31 $311.58
50972............ Ureter endoscopy & Y................ ................. A2............... $333.00 5.9735 $247.31 $311.58
catheter.
50974............ Ureter endoscopy & Y................ ................. A2............... $333.00 17.942 $742.82 $435.46
biopsy.
50976............ Ureter endoscopy & Y................ ................. A2............... $333.00 17.942 $742.82 $435.46
treatment.
50980............ Ureter endoscopy & Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
treatment.
51000............ Drainage of bladder..... N................ CH............... D5............... ........... ........... ........... ...........
51005............ Drainage of bladder..... N................ CH............... D5............... ........... ........... ........... ...........
51010............ Drainage of bladder..... N................ CH............... D5............... ........... ........... ........... ...........
51020............ Incise & treat bladder.. Y................ ................. A2............... $630.00 24.7749 $1,025.71 $728.93
51030............ Incise & treat bladder.. Y................ ................. A2............... $630.00 24.7749 $1,025.71 $728.93
51040............ Incise & drain bladder.. Y................ ................. A2............... $630.00 24.7749 $1,025.71 $728.93
51045............ Incise bladder/drain Y................ ................. A2............... $399.24 5.9735 $247.31 $361.26
ureter.
51050............ Removal of bladder stone Y................ ................. A2............... $630.00 24.7749 $1,025.71 $728.93
51065............ Remove ureter calculus.. Y................ ................. A2............... $630.00 24.7749 $1,025.71 $728.93
51080............ Drainage of bladder Y................ ................. A2............... $333.00 18.3197 $758.45 $439.36
abscess.
51100............ Drain bladder by needle. Y................ NI............... P3............... ........... 0.757 $31.34 $31.34
51101............ Drain bladder by trocar/ Y................ NI............... P2............... ........... 1.0356 $42.87 $42.87
cath.
51102............ Drain bl w/cath Y................ NI............... A2............... $333.00 19.3414 $800.75 $449.94
insertion.
51500............ Removal of bladder cyst. Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
51520............ Removal of bladder Y................ ................. A2............... $630.00 24.7749 $1,025.71 $728.93
lesion.
51600............ Injection for bladder x- N................ ................. N1............... ........... ........... ........... ...........
ray.
51605............ Preparation for bladder N................ ................. N1............... ........... ........... ........... ...........
xray.
51610............ Injection for bladder x- N................ ................. N1............... ........... ........... ........... ...........
ray.
51700............ Irrigation of bladder... Y................ ................. P3............... ........... 1.2756 $52.81 $52.81
51701............ Insert bladder catheter. N................ ................. P2............... ........... 0.631 $26.12 $26.12
51702............ Insert temp bladder cath N................ ................. P2............... ........... 0.631 $26.12 $26.12
51703............ Insert bladder cath, Y................ ................. P2............... ........... 1.0356 $42.87 $42.87
complex.
51705............ Change of bladder tube.. Y................ ................. P3............... ........... 1.7693 $73.25 $73.25
51710............ Change of bladder tube.. Y................ ................. A2............... $333.00 15.3545 $635.69 $408.67
51715............ Endoscopic injection/ Y................ ................. A2............... $510.00 29.7864 $1,233.19 $690.80
implant.
51720............ Treatment of bladder Y................ ................. P3............... ........... 1.3823 $57.23 $57.23
lesion.
51725............ Simple cystometrogram... Y................ ................. P2............... ........... 3.0469 $126.14 $126.14
51726............ Complex cystometrogram.. Y................ ................. A2............... $209.48 3.0469 $126.14 $188.65
51736............ Urine flow measurement.. Y................ ................. P3............... ........... 0.4444 $18.40 $18.40
51741............ Electro-uroflowmetry, Y................ ................. P3............... ........... 0.5101 $21.12 $21.12
first.
51772............ Urethra pressure profile Y................ ................. A2............... $131.50 2.0077 $83.12 $119.41
51784............ Anal/urinary muscle Y................ ................. P2............... ........... 1.0356 $42.87 $42.87
study.
51785............ Anal/urinary muscle Y................ ................. A2............... $66.92 2.0077 $83.12 $70.97
study.
51792............ Urinary reflex study.... Y................ ................. P2............... ........... 1.0356 $42.87 $42.87
51795............ Urine voiding pressure Y................ ................. P2............... ........... 2.0077 $83.12 $83.12
study.
51797............ Intraabdominal pressure Y................ ................. P2............... ........... 2.0077 $83.12 $83.12
test.
51798............ Us urine capacity N................ ................. P3............... ........... 0.3867 $16.01 $16.01
measure.
51880............ Repair of bladder Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
opening.
51992............ Laparo sling operation.. Y................ ................. A2............... $717.00 45.5317 $1,885.06 $1,009.02
52000............ Cystoscopy.............. Y................ ................. A2............... $333.00 5.9735 $247.31 $311.58
[[Page 66980]]
52001............ Cystoscopy, removal of Y................ ................. A2............... $399.24 17.942 $742.82 $485.14
clots.
52005............ Cystoscopy & ureter Y................ ................. A2............... $446.00 17.942 $742.82 $520.21
catheter.
52007............ Cystoscopy and biopsy... Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52010............ Cystoscopy & duct Y................ ................. A2............... $399.24 5.9735 $247.31 $361.26
catheter.
52204............ Cystoscopy w/biopsy(s).. Y................ ................. A2............... $446.00 17.942 $742.82 $520.21
52214............ Cystoscopy and treatment Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52224............ Cystoscopy and treatment Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52234............ Cystoscopy and treatment Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52235............ Cystoscopy and treatment Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
52240............ Cystoscopy and treatment Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
52250............ Cystoscopy and Y................ ................. A2............... $630.00 24.7749 $1,025.71 $728.93
radiotracer.
52260............ Cystoscopy and treatment Y................ ................. A2............... $446.00 17.942 $742.82 $520.21
52265............ Cystoscopy and treatment Y................ ................. P2............... ........... 5.9735 $247.31 $247.31
52270............ Cystoscopy & revise Y................ ................. A2............... $446.00 17.942 $742.82 $520.21
urethra.
52275............ Cystoscopy & revise Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
urethra.
52276............ Cystoscopy and treatment Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
52277............ Cystoscopy and treatment Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52281............ Cystoscopy and treatment Y................ ................. A2............... $446.00 17.942 $742.82 $520.21
52282............ Cystoscopy, implant Y................ ................. A2............... $1,339.00 36.0774 $1,493.64 $1,377.66
stent.
52283............ Cystoscopy and treatment Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52285............ Cystoscopy and treatment Y................ ................. A2............... $446.00 17.942 $742.82 $520.21
52290............ Cystoscopy and treatment Y................ ................. A2............... $446.00 17.942 $742.82 $520.21
52300............ Cystoscopy and treatment Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52301............ Cystoscopy and treatment Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
52305............ Cystoscopy and treatment Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52310............ Cystoscopy and treatment Y................ ................. A2............... $399.24 17.942 $742.82 $485.14
52315............ Cystoscopy and treatment Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52317............ Remove bladder stone.... Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
52318............ Remove bladder stone.... Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52320............ Cystoscopy and treatment Y................ ................. A2............... $717.00 24.7749 $1,025.71 $794.18
52325............ Cystoscopy, stone Y................ ................. A2............... $630.00 24.7749 $1,025.71 $728.93
removal.
52327............ Cystoscopy, inject Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
material.
52330............ Cystoscopy and treatment Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52332............ Cystoscopy and treatment Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
52334............ Create passage to kidney Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
52341............ Cysto w/ureter stricture Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
tx.
52342............ Cysto w/up stricture tx. Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
52343............ Cysto w/renal stricture Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
tx.
52344............ Cysto/uretero, stricture Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
tx.
52345............ Cysto/uretero w/up Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
stricture.
52346............ Cystouretero w/renal Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
strict.
52351............ Cystouretero & or Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
pyeloscope.
52352............ Cystouretero w/stone Y................ ................. A2............... $630.00 24.7749 $1,025.71 $728.93
remove.
52353............ Cystouretero w/ Y................ ................. A2............... $630.00 36.0774 $1,493.64 $845.91
lithotripsy.
52354............ Cystouretero w/biopsy... Y................ ................. A2............... $630.00 24.7749 $1,025.71 $728.93
52355............ Cystouretero w/excise Y................ ................. A2............... $630.00 24.7749 $1,025.71 $728.93
tumor.
52400............ Cystouretero w/congen Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
repr.
52402............ Cystourethro cut ejacul Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
duct.
52450............ Incision of prostate.... Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
52500............ Revision of bladder neck Y................ ................. A2............... $510.00 24.7749 $1,025.71 $638.93
52510............ Dilation prostatic N................ CH............... D5............... ........... ........... ........... ...........
urethra.
52601............ Prostatectomy (turp).... Y................ ................. A2............... $630.00 36.0774 $1,493.64 $845.91
52606............ Control postop bleeding. Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
52612............ Prostatectomy, first Y................ ................. A2............... $446.00 36.0774 $1,493.64 $707.91
stage.
52614............ Prostatectomy, second Y................ ................. A2............... $333.00 36.0774 $1,493.64 $623.16
stage.
52620............ Remove residual prostate Y................ ................. A2............... $333.00 36.0774 $1,493.64 $623.16
52630............ Remove prostate regrowth Y................ ................. A2............... $446.00 36.0774 $1,493.64 $707.91
52640............ Relieve bladder Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
contracture.
52647............ Laser surgery of Y................ ................. A2............... $1,339.00 45.2042 $1,871.50 $1,472.13
prostate.
52648............ Laser surgery of Y................ ................. A2............... $1,339.00 45.2042 $1,871.50 $1,472.13
prostate.
52700............ Drainage of prostate Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
abscess.
53000............ Incision of urethra..... Y................ ................. A2............... $333.00 19.1505 $792.85 $447.96
53010............ Incision of urethra..... Y................ ................. A2............... $333.00 19.1505 $792.85 $447.96
53020............ Incision of urethra..... Y................ ................. A2............... $333.00 19.1505 $792.85 $447.96
53025............ Incision of urethra..... Y................ ................. R2............... ........... 19.1505 $792.85 $792.85
53040............ Drainage of urethra Y................ ................. A2............... $446.00 19.1505 $792.85 $532.71
abscess.
53060............ Drainage of urethra Y................ ................. P3............... ........... 1.7198 $71.20 $71.20
abscess.
53080............ Drainage of urinary Y................ ................. A2............... $510.00 19.1505 $792.85 $580.71
leakage.
53085............ Drainage of urinary Y................ ................. G2............... ........... 19.1505 $792.85 $792.85
leakage.
53200............ Biopsy of urethra....... Y................ ................. A2............... $333.00 19.1505 $792.85 $447.96
53210............ Removal of urethra...... Y................ ................. A2............... $717.00 29.7864 $1,233.19 $846.05
53215............ Removal of urethra...... Y................ ................. A2............... $717.00 19.1505 $792.85 $735.96
53220............ Treatment of urethra Y................ ................. A2............... $446.00 29.7864 $1,233.19 $642.80
lesion.
[[Page 66981]]
53230............ Removal of urethra Y................ ................. A2............... $446.00 29.7864 $1,233.19 $642.80
lesion.
53235............ Removal of urethra Y................ ................. A2............... $510.00 19.1505 $792.85 $580.71
lesion.
53240............ Surgery for urethra Y................ ................. A2............... $446.00 29.7864 $1,233.19 $642.80
pouch.
53250............ Removal of urethra gland Y................ ................. A2............... $446.00 19.1505 $792.85 $532.71
53260............ Treatment of urethra Y................ ................. A2............... $446.00 19.1505 $792.85 $532.71
lesion.
53265............ Treatment of urethra Y................ ................. A2............... $446.00 19.1505 $792.85 $532.71
lesion.
53270............ Removal of urethra gland Y................ ................. A2............... $446.00 19.1505 $792.85 $532.71
53275............ Repair of urethra defect Y................ ................. A2............... $446.00 19.1505 $792.85 $532.71
53400............ Revise urethra, stage 1. Y................ ................. A2............... $510.00 29.7864 $1,233.19 $690.80
53405............ Revise urethra, stage 2. Y................ ................. A2............... $446.00 29.7864 $1,233.19 $642.80
53410............ Reconstruction of Y................ ................. A2............... $446.00 29.7864 $1,233.19 $642.80
urethra.
53420............ Reconstruct urethra, Y................ ................. A2............... $510.00 29.7864 $1,233.19 $690.80
stage 1.
53425............ Reconstruct urethra, Y................ ................. A2............... $446.00 29.7864 $1,233.19 $642.80
stage 2.
53430............ Reconstruction of Y................ ................. A2............... $446.00 29.7864 $1,233.19 $642.80
urethra.
53431............ Reconstruct urethra/ Y................ ................. A2............... $446.00 29.7864 $1,233.19 $642.80
bladder.
53440............ Male sling procedure.... N................ CH............... H8............... $446.00 106.8568 $4,423.98 $3,500.50
53442............ Remove/revise male sling Y................ ................. A2............... $333.00 29.7864 $1,233.19 $558.05
53444............ Insert tandem cuff...... N................ CH............... H8............... $446.00 106.8568 $4,423.98 $3,500.50
53445............ Insert uro/ves nck N................ ................. H8............... $333.00 193.4277 $8,008.10 $6,625.75
sphincter.
53446............ Remove uro sphincter.... Y................ ................. A2............... $333.00 29.7864 $1,233.19 $558.05
53447............ Remove/replace ur N................ ................. H8............... $333.00 193.4277 $8,008.10 $6,625.75
sphincter.
53449............ Repair uro sphincter.... Y................ ................. A2............... $333.00 29.7864 $1,233.19 $558.05
53450............ Revision of urethra..... Y................ ................. A2............... $333.00 29.7864 $1,233.19 $558.05
53460............ Revision of urethra..... Y................ ................. A2............... $333.00 19.1505 $792.85 $447.96
53502............ Repair of urethra injury Y................ ................. A2............... $446.00 19.1505 $792.85 $532.71
53505............ Repair of urethra injury Y................ ................. A2............... $446.00 29.7864 $1,233.19 $642.80
53510............ Repair of urethra injury Y................ ................. A2............... $446.00 19.1505 $792.85 $532.71
53515............ Repair of urethra injury Y................ ................. A2............... $446.00 29.7864 $1,233.19 $642.80
53520............ Repair of urethra defect Y................ ................. A2............... $446.00 29.7864 $1,233.19 $642.80
53600............ Dilate urethra stricture Y................ ................. P3............... ........... 0.9381 $38.84 $38.84
53601............ Dilate urethra stricture Y................ CH............... P2............... ........... 1.0356 $42.87 $42.87
53605............ Dilate urethra stricture Y................ ................. A2............... $446.00 17.942 $742.82 $520.21
53620............ Dilate urethra stricture Y................ ................. P3............... ........... 1.5142 $62.69 $62.69
53621............ Dilate urethra stricture Y................ ................. P3............... ........... 1.5963 $66.09 $66.09
53660............ Dilation of urethra..... Y................ CH............... P2............... ........... 1.0356 $42.87 $42.87
53661............ Dilation of urethra..... Y................ CH............... P2............... ........... 1.0356 $42.87 $42.87
53665............ Dilation of urethra..... Y................ ................. A2............... $333.00 19.1505 $792.85 $447.96
53850............ Prostatic microwave Y................ ................. P2............... ........... 45.2042 $1,871.50 $1,871.50
thermotx.
53852............ Prostatic rf thermotx... Y................ ................. P2............... ........... 45.2042 $1,871.50 $1,871.50
53853............ Prostatic water Y................ ................. P2............... ........... 24.7749 $1,025.71 $1,025.71
thermother.
54000............ Slitting of prepuce..... Y................ ................. A2............... $446.00 19.1505 $792.85 $532.71
54001............ Slitting of prepuce..... Y................ ................. A2............... $446.00 19.1505 $792.85 $532.71
54015............ Drain penis lesion...... Y................ ................. A2............... $630.00 18.3197 $758.45 $662.11
54050............ Destruction, penis Y................ ................. P2............... ........... 1.4595 $60.42 $60.42
lesion(s).
54055............ Destruction, penis Y................ ................. P3............... ........... 1.4565 $60.30 $60.30
lesion(s).
54056............ Cryosurgery, penis Y................ ................. P2............... ........... 0.793 $32.83 $32.83
lesion(s).
54057............ Laser surg, penis Y................ ................. A2............... $333.00 19.9041 $824.05 $455.76
lesion(s).
54060............ Excision of penis Y................ ................. A2............... $333.00 19.9041 $824.05 $455.76
lesion(s).
54065............ Destruction, penis Y................ ................. A2............... $333.00 19.9041 $824.05 $455.76
lesion(s).
54100............ Biopsy of penis......... Y................ ................. A2............... $333.00 16.1001 $666.56 $416.39
54105............ Biopsy of penis......... Y................ ................. A2............... $333.00 21.1098 $873.97 $468.24
54110............ Treatment of penis Y................ ................. A2............... $446.00 33.9306 $1,404.76 $685.69
lesion.
54111............ Treat penis lesion, Y................ ................. A2............... $446.00 33.9306 $1,404.76 $685.69
graft.
54112............ Treat penis lesion, Y................ ................. A2............... $446.00 33.9306 $1,404.76 $685.69
graft.
54115............ Treatment of penis Y................ ................. A2............... $333.00 18.3197 $758.45 $439.36
lesion.
54120............ Partial removal of penis Y................ ................. A2............... $446.00 33.9306 $1,404.76 $685.69
54150............ Circumcision w/regionl Y................ ................. A2............... $333.00 22.3251 $924.28 $480.82
block.
54160............ Circumcision, neonate... Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
54161............ Circum 28 days or older. Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
54162............ Lysis penil circumic Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
lesion.
54163............ Repair of circumcision.. Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
54164............ Frenulotomy of penis.... Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
54200............ Treatment of penis Y................ ................. P3............... ........... 1.5635 $64.73 $64.73
lesion.
54205............ Treatment of penis Y................ ................. A2............... $630.00 33.9306 $1,404.76 $823.69
lesion.
54220............ Treatment of penis Y................ ................. A2............... $131.50 2.0077 $83.12 $119.41
lesion.
54230............ Prepare penis study..... N................ ................. N1............... ........... ........... ........... ...........
54231............ Dynamic cavernosometry.. Y................ ................. P3............... ........... 1.3741 $56.89 $56.89
54235............ Penile injection........ Y................ ................. P3............... ........... 0.9628 $39.86 $39.86
54240............ Penis study............. Y................ ................. P3............... ........... 0.6667 $27.60 $27.60
54250............ Penis study............. Y................ ................. P3............... ........... 0.2304 $9.54 $9.54
54300............ Revision of penis....... Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
54304............ Revision of penis....... Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
54308............ Reconstruction of Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
urethra.
[[Page 66982]]
54312............ Reconstruction of Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
urethra.
54316............ Reconstruction of Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
urethra.
54318............ Reconstruction of Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
urethra.
54322............ Reconstruction of Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
urethra.
54324............ Reconstruction of Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
urethra.
54326............ Reconstruction of Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
urethra.
54328............ Revise penis/urethra.... Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
54340............ Secondary urethral Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
surgery.
54344............ Secondary urethral Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
surgery.
54348............ Secondary urethral Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
surgery.
54352............ Reconstruct urethra/ Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
penis.
54360............ Penis plastic surgery... Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
54380............ Repair penis............ Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
54385............ Repair penis............ Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
54400............ Insert semi-rigid N................ CH............... H8............... $510.00 106.8568 $4,423.98 $3,548.50
prosthesis.
54401............ Insert self-contd N................ ................. H8............... $510.00 193.4277 $8,008.10 $6,758.50
prosthesis.
54405............ Insert multi-comp penis N................ ................. H8............... $510.00 193.4277 $8,008.10 $6,758.50
pros.
54406............ Remove muti-comp penis Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
pros.
54408............ Repair multi-comp penis Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
pros.
54410............ Remove/replace penis N................ ................. H8............... $510.00 193.4277 $8,008.10 $6,758.50
prosth.
54415............ Remove self-contd penis Y................ ................. A2............... $510.00 33.9306 $1,404.76 $733.69
pros.
54416............ Remv/repl penis contain N................ ................. H8............... $510.00 193.4277 $8,008.10 $6,758.50
pros.
54420............ Revision of penis....... Y................ ................. A2............... $630.00 33.9306 $1,404.76 $823.69
54435............ Revision of penis....... Y................ ................. A2............... $630.00 33.9306 $1,404.76 $823.69
54440............ Repair of penis......... Y................ ................. A2............... $630.00 33.9306 $1,404.76 $823.69
54450............ Preputial stretching.... Y................ ................. A2............... $209.48 3.0469 $126.14 $188.65
54500............ Biopsy of testis........ Y................ ................. A2............... $333.00 13.5764 $562.08 $390.27
54505............ Biopsy of testis........ Y................ ................. A2............... $333.00 22.3251 $924.28 $480.82
54512............ Excise lesion testis.... Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
54520............ Removal of testis....... Y................ ................. A2............... $510.00 22.3251 $924.28 $613.57
54522............ Orchiectomy, partial.... Y................ ................. A2............... $510.00 22.3251 $924.28 $613.57
54530............ Removal of testis....... Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
54550............ Exploration for testis.. Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
54560............ Exploration for testis.. Y................ ................. G2............... ........... 22.3251 $924.28 $924.28
54600............ Reduce testis torsion... Y................ ................. A2............... $630.00 22.3251 $924.28 $703.57
54620............ Suspension of testis.... Y................ ................. A2............... $510.00 22.3251 $924.28 $613.57
54640............ Suspension of testis.... Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
54660............ Revision of testis...... Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
54670............ Repair testis injury.... Y................ ................. A2............... $510.00 22.3251 $924.28 $613.57
54680............ Relocation of testis(es) Y................ ................. A2............... $510.00 22.3251 $924.28 $613.57
54690............ Laparoscopy, orchiectomy Y................ ................. A2............... $1,339.00 45.5317 $1,885.06 $1,475.52
54692............ Laparoscopy, orchiopexy. Y................ ................. G2............... ........... 69.6652 $2,884.21 $2,884.21
54700............ Drainage of scrotum..... Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
54800............ Biopsy of epididymis.... Y................ ................. A2............... $127.16 4.327 $179.14 $140.16
54830............ Remove epididymis lesion Y................ ................. A2............... $510.00 22.3251 $924.28 $613.57
54840............ Remove epididymis lesion Y................ ................. A2............... $630.00 22.3251 $924.28 $703.57
54860............ Removal of epididymis... Y................ ................. A2............... $510.00 22.3251 $924.28 $613.57
54861............ Removal of epididymis... Y................ ................. A2............... $630.00 22.3251 $924.28 $703.57
54865............ Explore epididymis...... Y................ ................. A2............... $333.00 22.3251 $924.28 $480.82
54900............ Fusion of spermatic Y................ ................. A2............... $630.00 22.3251 $924.28 $703.57
ducts.
54901............ Fusion of spermatic Y................ ................. A2............... $630.00 22.3251 $924.28 $703.57
ducts.
55000............ Drainage of hydrocele... Y................ ................. P3............... ........... 1.6128 $66.77 $66.77
55040............ Removal of hydrocele.... Y................ ................. A2............... $510.00 30.6788 $1,270.13 $700.03
55041............ Removal of hydroceles... Y................ ................. A2............... $717.00 30.6788 $1,270.13 $855.28
55060............ Repair of hydrocele..... Y................ ................. A2............... $630.00 22.3251 $924.28 $703.57
55100............ Drainage of scrotum Y................ ................. A2............... $333.00 11.5594 $478.57 $369.39
abscess.
55110............ Explore scrotum......... Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
55120............ Removal of scrotum Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
lesion.
55150............ Removal of scrotum...... Y................ ................. A2............... $333.00 22.3251 $924.28 $480.82
55175............ Revision of scrotum..... Y................ ................. A2............... $333.00 22.3251 $924.28 $480.82
55180............ Revision of scrotum..... Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
55200............ Incision of sperm duct.. Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
55250............ Removal of sperm duct(s) Y................ ................. A2............... $446.00 22.3251 $924.28 $565.57
55300............ Prepare, sperm duct x- N................ ................. N1............... ........... ........... ........... ...........
ray.
55400............ Repair of sperm duct.... Y................ ................. A2............... $333.00 22.3251 $924.28 $480.82
55450............ Ligation of sperm duct.. Y................ ................. P3............... ........... 5.1182 $211.90 $211.90
55500............ Removal of hydrocele.... Y................ ................. A2............... $510.00 22.3251 $924.28 $613.57
55520............ Removal of sperm cord Y................ ................. A2............... $630.00 22.3251 $924.28 $703.57
lesion.
55530............ Revise spermatic cord Y................ ................. A2............... $630.00 22.3251 $924.28 $703.57
veins.
55535............ Revise spermatic cord Y................ ................. A2............... $630.00 30.6788 $1,270.13 $790.03
veins.
55540............ Revise hernia & sperm Y................ ................. A2............... $717.00 30.6788 $1,270.13 $855.28
veins.
55550............ Laparo ligate spermatic Y................ ................. A2............... $1,339.00 45.5317 $1,885.06 $1,475.52
vein.
55600............ Incise sperm duct pouch. Y................ ................. R2............... ........... 22.3251 $924.28 $924.28
[[Page 66983]]
55680............ Remove sperm pouch Y................ ................. A2............... $333.00 22.3251 $924.28 $480.82
lesion.
55700............ Biopsy of prostate...... Y................ ................. A2............... $345.83 11.0338 $456.81 $373.58
55705............ Biopsy of prostate...... Y................ ................. A2............... $345.83 11.0338 $456.81 $373.58
55720............ Drainage of prostate Y................ ................. A2............... $333.00 24.7749 $1,025.71 $506.18
abscess.
55725............ Drainage of prostate Y................ ................. A2............... $446.00 24.7749 $1,025.71 $590.93
abscess.
55860............ Surgical exposure, Y................ ................. G2............... ........... 19.3414 $800.75 $800.75
prostate.
55870............ Electroejaculation...... Y................ ................. P3............... ........... 1.6541 $68.48 $68.48
55873............ Cryoablate prostate..... Y................ ................. H8............... $1,339.00 162.5379 $6,729.23 $6,219.63
55875............ Transperi needle place, N................ ................. A2............... $1,339.00 36.0774 $1,493.64 $1,377.66
pros.
55876*........... Place rt device/marker, Y................ ................. P3............... ........... 1.7033 $70.52 $70.52
pros.
55920............ Place needles pelvic for Y................ NI............... G2............... ........... 25.6947 $1,063.79 $1,063.79
rt.
56405............ I & d of vulva/perineum. Y................ ................. P3............... ........... 1.0287 $42.59 $42.59
56420............ Drainage of gland Y................ ................. P2............... ........... 1.352 $55.97 $55.97
abscess.
56440............ Surgery for vulva lesion Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
56441............ Lysis of labial Y................ ................. A2............... $333.00 19.0203 $787.46 $446.62
lesion(s).
56442............ Hymenotomy.............. Y................ ................. A2............... $333.00 19.0203 $787.46 $446.62
56501............ Destroy, vulva lesions, Y................ ................. P3............... ........... 1.4072 $58.26 $58.26
sim.
56515............ Destroy vulva lesion/s Y................ ................. A2............... $510.00 19.9041 $824.05 $588.51
compl.
56605............ Biopsy of vulva/perineum Y................ ................. P3............... ........... 0.8229 $34.07 $34.07
56606............ Biopsy of vulva/perineum Y................ ................. P3............... ........... 0.3456 $14.31 $14.31
56620............ Partial removal of vulva Y................ ................. A2............... $717.00 19.0203 $787.46 $734.62
56625............ Complete removal of Y................ ................. A2............... $995.00 19.0203 $787.46 $943.12
vulva.
56700............ Partial removal of hymen Y................ ................. A2............... $333.00 19.0203 $787.46 $446.62
56740............ Remove vagina gland Y................ ................. A2............... $510.00 19.0203 $787.46 $579.37
lesion.
56800............ Repair of vagina........ Y................ ................. A2............... $510.00 19.0203 $787.46 $579.37
56805............ Repair clitoris......... Y................ ................. G2............... ........... 19.0203 $787.46 $787.46
56810............ Repair of perineum...... Y................ ................. A2............... $717.00 19.0203 $787.46 $734.62
56820............ Exam of vulva w/scope... Y................ ................. P3............... ........... 1.0287 $42.59 $42.59
56821............ Exam/biopsy of vulva w/ Y................ ................. P3............... ........... 1.3495 $55.87 $55.87
scope.
57000............ Exploration of vagina... Y................ ................. A2............... $333.00 19.0203 $787.46 $446.62
57010............ Drainage of pelvic Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
abscess.
57020............ Drainage of pelvic fluid Y................ ................. A2............... $409.33 6.0783 $251.65 $369.91
57022............ I & d vaginal hematoma, Y................ ................. G2............... ........... 11.5594 $478.57 $478.57
pp.
57023............ I & d vag hematoma, non- Y................ ................. A2............... $333.00 18.3197 $758.45 $439.36
ob.
57061............ Destroy vag lesions, Y................ ................. P3............... ........... 1.3002 $53.83 $53.83
simple.
57065............ Destroy vag lesions, Y................ ................. A2............... $333.00 19.0203 $787.46 $446.62
complex.
57100............ Biopsy of vagina........ Y................ ................. P3............... ........... 0.8311 $34.41 $34.41
57105............ Biopsy of vagina........ Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
57130............ Remove vagina lesion.... Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
57135............ Remove vagina lesion.... Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
57150............ Treat vagina infection.. Y................ CH............... P3............... ........... 0.6913 $28.62 $28.62
57155............ Insert uteri tandems/ Y................ ................. A2............... $409.33 6.0783 $251.65 $369.91
ovoids.
57160............ Insert pessary/other Y................ ................. P3............... ........... 0.8476 $35.09 $35.09
device.
57170............ Fitting of diaphragm/cap Y................ ................. P2............... ........... 0.1309 $5.42 $5.42
57180............ Treat vaginal bleeding.. Y................ ................. A2............... $178.05 1.352 $55.97 $147.53
57200............ Repair of vagina........ Y................ ................. A2............... $333.00 19.0203 $787.46 $446.62
57210............ Repair vagina/perineum.. Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
57220............ Revision of urethra..... Y................ ................. A2............... $510.00 42.7099 $1,768.23 $824.56
57230............ Repair of urethral Y................ ................. A2............... $510.00 32.4237 $1,342.37 $718.09
lesion.
57240............ Repair bladder & vagina. Y................ ................. A2............... $717.00 32.4237 $1,342.37 $873.34
57250............ Repair rectum & vagina.. Y................ ................. A2............... $717.00 32.4237 $1,342.37 $873.34
57260............ Repair of vagina........ Y................ ................. A2............... $717.00 32.4237 $1,342.37 $873.34
57265............ Extensive repair of Y................ ................. A2............... $995.00 42.7099 $1,768.23 $1,188.31
vagina.
57267............ Insert mesh/pelvic flr Y................ ................. A2............... $995.00 32.4237 $1,342.37 $1,081.84
addon.
57268............ Repair of bowel bulge... Y................ ................. A2............... $510.00 32.4237 $1,342.37 $718.09
57287............ Revise/remove sling Y................ ................. G2............... ........... 32.4237 $1,342.37 $1,342.37
repair.
57288............ Repair bladder defect... Y................ ................. A2............... $717.00 42.7099 $1,768.23 $979.81
57289............ Repair bladder & vagina. Y................ ................. A2............... $717.00 32.4237 $1,342.37 $873.34
57291............ Construction of vagina.. Y................ ................. A2............... $717.00 32.4237 $1,342.37 $873.34
57300............ Repair rectum-vagina Y................ ................. A2............... $510.00 32.4237 $1,342.37 $718.09
fistula.
57320............ Repair bladder-vagina Y................ ................. G2............... ........... 32.4237 $1,342.37 $1,342.37
lesion.
57400............ Dilation of vagina...... Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
57410............ Pelvic examination...... Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
57415............ Remove vaginal foreign Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
body.
57420............ Exam of vagina w/scope.. Y................ ................. P3............... ........... 1.0616 $43.95 $43.95
57421............ Exam/biopsy of vag w/ Y................ ................. P3............... ........... 1.4154 $58.60 $58.60
scope.
57452............ Exam of cervix w/scope.. Y................ ................. P3............... ........... 1.0121 $41.90 $41.90
57454............ Bx/curett of cervix w/ Y................ ................. P3............... ........... 1.2425 $51.44 $51.44
scope.
57455............ Biopsy of cervix w/scope Y................ ................. P3............... ........... 1.3248 $54.85 $54.85
57456............ Endocerv curettage w/ Y................ ................. P3............... ........... 1.2756 $52.81 $52.81
scope.
57460............ Bx of cervix w/scope, Y................ ................. P3............... ........... 4.1639 $172.39 $172.39
leep.
57461............ Conz of cervix w/scope, Y................ ................. P3............... ........... 4.3859 $181.58 $181.58
leep.
57500............ Biopsy of cervix........ Y................ ................. P3............... ........... 1.8763 $77.68 $77.68
[[Page 66984]]
57505............ Endocervical curettage.. Y................ ................. P3............... ........... 1.1437 $47.35 $47.35
57510............ Cauterization of cervix. Y................ ................. P3............... ........... 1.1768 $48.72 $48.72
57511............ Cryocautery of cervix... Y................ ................. P2............... ........... 1.352 $55.97 $55.97
57513............ Laser surgery of cervix. Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
57520............ Conization of cervix.... Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
57522............ Conization of cervix.... Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
57530............ Removal of cervix....... Y................ ................. A2............... $510.00 32.4237 $1,342.37 $718.09
57550............ Removal of residual Y................ ................. A2............... $510.00 32.4237 $1,342.37 $718.09
cervix.
57556............ Remove cervix, repair Y................ ................. A2............... $717.00 42.7099 $1,768.23 $979.81
bowel.
57558............ D&c of cervical stump... Y................ ................. A2............... $510.00 19.0203 $787.46 $579.37
57700............ Revision of cervix...... Y................ ................. A2............... $333.00 19.0203 $787.46 $446.62
57720............ Revision of cervix...... Y................ ................. A2............... $510.00 19.0203 $787.46 $579.37
57800............ Dilation of cervical Y................ ................. P3............... ........... 0.6089 $25.21 $25.21
canal.
58100............ Biopsy of uterus lining. Y................ ................. P3............... ........... 1.0121 $41.90 $41.90
58110............ Bx done w/colposcopy add- N................ CH............... N1............... ........... ........... ........... ...........
on.
58120............ Dilation and curettage.. Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
58145............ Myomectomy vag method... Y................ ................. A2............... $717.00 32.4237 $1,342.37 $873.34
58301............ Remove intrauterine Y................ ................. P3............... ........... 0.971 $40.20 $40.20
device.
58321............ Artificial insemination. Y................ ................. P3............... ........... 0.8558 $35.43 $35.43
58322............ Artificial insemination. Y................ ................. P3............... ........... 0.9135 $37.82 $37.82
58323............ Sperm washing........... Y................ ................. P3............... ........... 0.2797 $11.58 $11.58
58340............ Catheter for N................ ................. N1............... ........... ........... ........... ...........
hysterography.
58345............ Reopen fallopian tube... Y................ ................. R2............... ........... 19.0203 $787.46 $787.46
58346............ Insert heyman uteri Y................ ................. A2............... $446.00 19.0203 $787.46 $531.37
capsule.
58350............ Reopen fallopian tube... Y................ ................. A2............... $510.00 32.4237 $1,342.37 $718.09
58353............ Endometr ablate, thermal Y................ ................. A2............... $995.00 32.4237 $1,342.37 $1,081.84
58356............ Endometrial cryoablation Y................ ................. P3............... ........... 43.0862 $1,783.81 $1,783.81
58545............ Laparoscopic myomectomy. Y................ ................. A2............... $1,339.00 34.3958 $1,424.02 $1,360.26
58546............ Laparo-myomectomy, Y................ ................. A2............... $1,339.00 45.5317 $1,885.06 $1,475.52
complex.
58550............ Laparo-asst vag Y................ ................. A2............... $1,339.00 69.6652 $2,884.21 $1,725.30
hysterectomy.
58552............ Laparo-vag hyst incl t/o Y................ ................. G2............... ........... 45.5317 $1,885.06 $1,885.06
58555............ Hysteroscopy, dx, sep Y................ ................. A2............... $333.00 21.6576 $896.65 $473.91
proc.
58558............ Hysteroscopy, biopsy.... Y................ ................. A2............... $510.00 21.6576 $896.65 $606.66
58559............ Hysteroscopy, lysis..... Y................ ................. A2............... $446.00 21.6576 $896.65 $558.66
58560............ Hysteroscopy, resect Y................ ................. A2............... $510.00 34.2048 $1,416.11 $736.53
septum.
58561............ Hysteroscopy, remove Y................ ................. A2............... $510.00 34.2048 $1,416.11 $736.53
myoma.
58562............ Hysteroscopy, remove fb. Y................ ................. A2............... $510.00 21.6576 $896.65 $606.66
58563............ Hysteroscopy, ablation.. Y................ ................. A2............... $1,339.00 34.2048 $1,416.11 $1,358.28
58565............ Hysteroscopy, Y................ ................. A2............... $1,339.00 42.7099 $1,768.23 $1,446.31
sterilization.
58600............ Division of fallopian Y................ ................. G2............... ........... 32.4237 $1,342.37 $1,342.37
tube.
58615............ Occlude fallopian Y................ ................. G2............... ........... 19.0203 $787.46 $787.46
tube(s).
58660............ Laparoscopy, lysis...... Y................ ................. A2............... $717.00 45.5317 $1,885.06 $1,009.02
58661............ Laparoscopy, remove Y................ ................. A2............... $717.00 45.5317 $1,885.06 $1,009.02
adnexa.
58662............ Laparoscopy, excise Y................ ................. A2............... $717.00 45.5317 $1,885.06 $1,009.02
lesions.
58670............ Laparoscopy, tubal Y................ ................. A2............... $510.00 45.5317 $1,885.06 $853.77
cautery.
58671............ Laparoscopy, tubal block Y................ ................. A2............... $510.00 45.5317 $1,885.06 $853.77
58672............ Laparoscopy, Y................ ................. A2............... $717.00 45.5317 $1,885.06 $1,009.02
fimbrioplasty.
58673............ Laparoscopy, Y................ ................. A2............... $717.00 45.5317 $1,885.06 $1,009.02
salpingostomy.
58800............ Drainage of ovarian Y................ ................. A2............... $510.00 19.0203 $787.46 $579.37
cyst(s).
58805............ Drainage of ovarian Y................ CH............... G2............... ........... 32.4237 $1,342.37 $1,342.37
cyst(s).
58820............ Drain ovary abscess, Y................ ................. A2............... $510.00 32.4237 $1,342.37 $718.09
open.
58900............ Biopsy of ovary(s)...... Y................ ................. A2............... $510.00 19.0203 $787.46 $579.37
58970............ Retrieval of oocyte..... Y................ ................. A2............... $245.92 2.7584 $114.20 $212.99
58974............ Transfer of embryo...... Y................ ................. A2............... $245.92 2.7584 $114.20 $212.99
58976............ Transfer of embryo...... Y................ ................. A2............... $245.92 2.7584 $114.20 $212.99
59000............ Amniocentesis, Y................ CH............... P3............... ........... 1.5717 $65.07 $65.07
diagnostic.
59001............ Amniocentesis, Y................ ................. R2............... ........... 6.0783 $251.65 $251.65
therapeutic.
59012............ Fetal cord Y................ ................. G2............... ........... 2.7584 $114.20 $114.20
puncture,prenatal.
59015............ Chorion biopsy.......... Y................ ................. P3............... ........... 1.2178 $50.42 $50.42
59020............ Fetal contract stress Y................ ................. P3............... ........... 0.5761 $23.85 $23.85
test.
59025............ Fetal non-stress test... Y................ ................. P3............... ........... 0.2961 $12.26 $12.26
59070............ Transabdom amnioinfus w/ Y................ ................. G2............... ........... 2.7584 $114.20 $114.20
us.
59072............ Umbilical cord occlud w/ Y................ ................. G2............... ........... 2.7584 $114.20 $114.20
us.
59076............ Fetal shunt placement, w/ Y................ ................. G2............... ........... 2.7584 $114.20 $114.20
us.
59100............ Remove uterus lesion.... Y................ ................. R2............... ........... 32.4237 $1,342.37 $1,342.37
59150............ Treat ectopic pregnancy. Y................ ................. G2............... ........... 45.5317 $1,885.06 $1,885.06
59151............ Treat ectopic pregnancy. Y................ ................. G2............... ........... 45.5317 $1,885.06 $1,885.06
59160............ D & c after delivery.... Y................ ................. A2............... $510.00 19.0203 $787.46 $579.37
59200............ Insert cervical dilator. Y................ ................. P3............... ........... 0.8722 $36.11 $36.11
59300............ Episiotomy or vaginal Y................ ................. P3............... ........... 1.7939 $74.27 $74.27
repair.
59320............ Revision of cervix...... Y................ ................. A2............... $333.00 19.0203 $787.46 $446.62
59412............ Antepartum manipulation. Y................ ................. G2............... ........... 19.0203 $787.46 $787.46
59414............ Deliver placenta........ Y................ ................. G2............... ........... 19.0203 $787.46 $787.46
[[Page 66985]]
59812............ Treatment of miscarriage Y................ ................. A2............... $717.00 19.0203 $787.46 $734.62
59820............ Care of miscarriage..... Y................ ................. A2............... $717.00 19.0203 $787.46 $734.62
59821............ Treatment of miscarriage Y................ ................. A2............... $717.00 19.0203 $787.46 $734.62
59840............ Abortion................ Y................ ................. A2............... $717.00 19.0203 $787.46 $734.62
59841............ Abortion................ Y................ ................. A2............... $717.00 19.0203 $787.46 $734.62
59866............ Abortion (mpr).......... Y................ ................. G2............... ........... 2.7584 $114.20 $114.20
59870............ Evacuate mole of uterus. Y................ ................. A2............... $717.00 19.0203 $787.46 $734.62
59871............ Remove cerclage suture.. Y................ ................. A2............... $717.00 19.0203 $787.46 $734.62
60000............ Drain thyroid/tongue Y................ ................. A2............... $333.00 7.4474 $308.33 $326.83
cyst.
60001............ Aspirate/inject thyriod N................ CH............... D5............... ........... ........... ........... ...........
cyst.
60100............ Biopsy of thyroid....... Y................ ................. P3............... ........... 1.1108 $45.99 $45.99
60200............ Remove thyroid lesion... Y................ ................. A2............... $446.00 44.324 $1,835.06 $793.27
60280............ Remove thyroid duct Y................ ................. A2............... $630.00 44.324 $1,835.06 $931.27
lesion.
60281............ Remove thyroid duct Y................ ................. A2............... $630.00 44.324 $1,835.06 $931.27
lesion.
60300............ Aspir/inj thyroid cyst.. Y................ NI............... P3............... ........... 1.3741 $56.89 $56.89
61000............ Remove cranial cavity Y................ ................. R2............... ........... 8.5263 $353.00 $353.00
fluid.
61001............ Remove cranial cavity Y................ ................. R2............... ........... 8.5263 $353.00 $353.00
fluid.
61020............ Remove brain cavity Y................ ................. A2............... $183.83 8.5263 $353.00 $226.12
fluid.
61026............ Injection into brain Y................ ................. A2............... $183.83 8.5263 $353.00 $226.12
canal.
61050............ Remove brain canal fluid Y................ ................. A2............... $183.83 8.5263 $353.00 $226.12
61055............ Injection into brain Y................ ................. A2............... $183.83 8.5263 $353.00 $226.12
canal.
61070............ Brain canal shunt Y................ ................. A2............... $183.83 3.2383 $134.07 $171.39
procedure.
61215............ Insert brain-fluid Y................ ................. A2............... $510.00 36.2768 $1,501.90 $757.98
device.
61330............ Decompress eye socket... Y................ ................. G2............... ........... 39.8776 $1,650.97 $1,650.97
61334............ Explore orbit/remove Y................ ................. G2............... ........... 39.8776 $1,650.97 $1,650.97
object.
61790............ Treat trigeminal nerve.. Y................ ................. A2............... $510.00 18.0518 $747.36 $569.34
61791............ Treat trigeminal tract.. Y................ ................. A2............... $351.92 14.4879 $599.81 $413.89
61795............ Brain surgery using N................ CH............... N1............... ........... ........... ........... ...........
computer.
61880............ Revise/remove Y................ ................. G2............... ........... 22.4734 $930.42 $930.42
neuroelectrode.
61885............ Insrt/redo neurostim 1 N................ ................. H8............... $446.00 269.543 $11,159.35 $10,493.89
array.
61886............ Implant neurostim arrays N................ ................. H8............... $510.00 395.2777 $16,364.89 $15,586.16
61888............ Revise/remove Y................ ................. A2............... $333.00 34.4166 $1,424.88 $605.97
neuroreceiver.
62194............ Replace/irrigate Y................ ................. A2............... $333.00 8.5263 $353.00 $338.00
catheter.
62225............ Replace/irrigate Y................ ................. A2............... $333.00 15.3545 $635.69 $408.67
catheter.
62230............ Replace/revise brain Y................ ................. A2............... $446.00 36.2768 $1,501.90 $709.98
shunt.
62252............ Csf shunt reprogram..... N................ ................. P3............... ........... 1.0698 $44.29 $44.29
62263............ Epidural lysis mult Y................ ................. A2............... $333.00 14.4879 $599.81 $399.70
sessions.
62264............ Epidural lysis on single Y................ ................. A2............... $333.00 14.4879 $599.81 $399.70
day.
62268............ Drain spinal cord cyst.. Y................ ................. A2............... $183.83 8.5263 $353.00 $226.12
62269............ Needle biopsy, spinal Y................ ................. A2............... $333.00 9.3354 $386.49 $346.37
cord.
62270............ Spinal fluid tap, Y................ ................. A2............... $139.00 4.0964 $169.60 $146.65
diagnostic.
62272............ Drain cerebro spinal Y................ ................. A2............... $139.00 4.0964 $169.60 $146.65
fluid.
62273............ Inject epidural patch... Y................ ................. A2............... $333.00 4.0964 $169.60 $292.15
62280............ Treat spinal cord lesion Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
62281............ Treat spinal cord lesion Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
62282............ Treat spinal canal Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
lesion.
62284............ Injection for myelogram. N................ ................. N1............... ........... ........... ........... ...........
62287............ Percutaneous diskectomy. Y................ ................. A2............... $1,339.00 33.2707 $1,377.44 $1,348.61
62290............ Inject for spine disk x- N................ ................. N1............... ........... ........... ........... ...........
ray.
62291............ Inject for spine disk x- N................ ................. N1............... ........... ........... ........... ...........
ray.
62292............ Injection into disk Y................ CH............... R2............... ........... 8.5263 $353.00 $353.00
lesion.
62294............ Injection into spinal Y................ ................. A2............... $183.83 8.5263 $353.00 $226.12
artery.
62310............ Inject spine c/t........ Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
62311............ Inject spine l/s (cd)... Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
62318............ Inject spine w/cath, c/t Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
62319............ Inject spine w/cath l/s Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
(cd).
62350............ Implant spinal canal Y................ ................. A2............... $446.00 36.2768 $1,501.90 $709.98
cath.
62355............ Remove spinal canal Y................ ................. A2............... $446.00 14.4879 $599.81 $484.45
catheter.
62360............ Insert spine infusion Y................ ................. A2............... $446.00 36.2768 $1,501.90 $709.98
device.
62361............ Implant spine infusion Y................ ................. H8............... $446.00 263.8315 $10,922.89 $10,157.07
pump.
62362............ Implant spine infusion Y................ ................. H8............... $446.00 263.8315 $10,922.89 $10,157.07
pump.
62365............ Remove spine infusion Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
device.
62367............ Analyze spine infusion N................ ................. P3............... ........... 0.428 $17.72 $17.72
pump.
62368............ Analyze spine infusion N................ ................. P3............... ........... 0.5183 $21.46 $21.46
pump.
63600............ Remove spinal cord Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
lesion.
63610............ Stimulation of spinal Y................ ................. A2............... $333.00 18.0518 $747.36 $436.59
cord.
63615............ Remove lesion of spinal Y................ ................. R2............... ........... 18.0518 $747.36 $747.36
cord.
63650............ Implant neuroelectrodes. N................ ................. H8............... $446.00 83.1135 $3,440.98 $2,909.36
63655............ Implant neuroelectrodes. N................ ................. J8............... ........... 109.8976 $4,549.87 $4,549.87
63660............ Revise/remove Y................ ................. A2............... $333.00 22.4734 $930.42 $482.36
neuroelectrode.
63685............ Insrt/redo spine n N................ ................. H8............... $446.00 350.8302 $14,524.72 $13,727.20
generator.
63688............ Revise/remove Y................ ................. A2............... $333.00 34.4166 $1,424.88 $605.97
neuroreceiver.
63744............ Revision of spinal shunt Y................ ................. A2............... $510.00 36.2768 $1,501.90 $757.98
[[Page 66986]]
63746............ Removal of spinal shunt. Y................ ................. A2............... $446.00 5.6614 $234.39 $393.10
64400............ N block inj, trigeminal. Y................ ................. P3............... ........... 1.3577 $56.21 $56.21
64402............ N block inj, facial..... Y................ ................. P3............... ........... 1.2425 $51.44 $51.44
64405............ N block inj, occipital.. Y................ ................. P3............... ........... 1.078 $44.63 $44.63
64408............ N block inj, vagus...... Y................ ................. P3............... ........... 1.2425 $51.44 $51.44
64410............ N block inj, phrenic.... Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
64412............ N block inj, spinal Y................ ................. P3............... ........... 1.9666 $81.42 $81.42
accessor.
64413............ N block inj, cervical Y................ ................. P3............... ........... 1.292 $53.49 $53.49
plexus.
64415............ N block inj, brachial Y................ ................. A2............... $139.00 4.0964 $169.60 $146.65
plexus.
64416............ N block cont infuse, b Y................ ................. G2............... ........... 7.0546 $292.07 $292.07
plex.
64417............ N block inj, axillary... Y................ ................. A2............... $139.00 4.0964 $169.60 $146.65
64418............ N block inj, Y................ ................. P3............... ........... 1.8596 $76.99 $76.99
suprascapular.
64420............ N block inj, intercost, Y................ ................. A2............... $139.00 4.0964 $169.60 $146.65
sng.
64421............ N block inj, intercost, Y................ ................. A2............... $333.00 4.0964 $169.60 $292.15
mlt.
64425............ N block inj, ilio-ing/ Y................ ................. P3............... ........... 1.2096 $50.08 $50.08
hypogi.
64430............ N block inj, pudendal... Y................ ................. A2............... $139.00 7.0546 $292.07 $177.27
64435............ N block inj, Y................ ................. P3............... ........... 1.8596 $76.99 $76.99
paracervical.
64445............ N block inj, sciatic, Y................ ................. P3............... ........... 1.7693 $73.25 $73.25
sng.
64446............ N blk inj, sciatic, cont Y................ ................. G2............... ........... 14.4879 $599.81 $599.81
inf.
64447............ N block inj fem, single. Y................ CH............... R2............... ........... 4.0964 $169.60 $169.60
64450............ N block, other Y................ ................. P3............... ........... 1.0287 $42.59 $42.59
peripheral.
64470............ Inj paravertebral c/t... Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
64472............ Inj paravertebral c/t Y................ ................. A2............... $333.00 4.0964 $169.60 $292.15
add-on.
64475............ Inj paravertebral l/s... Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
64476............ Inj paravertebral l/s Y................ ................. A2............... $333.00 2.3213 $96.10 $273.78
add-on.
64479............ Inj foramen epidural c/t Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
64480............ Inj foramen epidural add- Y................ ................. A2............... $333.00 4.0964 $169.60 $292.15
on.
64483............ Inj foramen epidural l/s Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
64484............ Inj foramen epidural add- Y................ ................. A2............... $333.00 4.0964 $169.60 $292.15
on.
64505............ N block, spenopalatine Y................ ................. P3............... ........... 0.971 $40.20 $40.20
gangl.
64508............ N block, carotid sinus s/ Y................ ................. P3............... ........... 2.2053 $91.30 $91.30
p.
64510............ N block, stellate Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
ganglion.
64517............ N block inj, hypogas Y................ ................. A2............... $139.00 7.0546 $292.07 $177.27
plxs.
64520............ N block, lumbar/thoracic Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
64530............ N block inj, celiac Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
pelus.
64553............ Implant neuroelectrodes. N................ ................. H8............... $333.00 316.5407 $13,105.10 $12,022.95
64555............ Implant neuroelectrodes. N................ ................. J8............... ........... 83.1135 $3,440.98 $3,440.98
64560............ Implant neuroelectrodes. N................ ................. J8............... ........... 83.1135 $3,440.98 $3,440.98
64561............ Implant neuroelectrodes. N................ ................. H8............... $510.00 83.1135 $3,440.98 $2,957.36
64565............ Implant neuroelectrodes. N................ ................. J8............... ........... 83.1135 $3,440.98 $3,440.98
64573............ Implant neuroelectrodes. N................ ................. H8............... $333.00 316.5407 $13,105.10 $12,022.95
64575............ Implant neuroelectrodes. N................ ................. H8............... $333.00 109.8976 $4,549.87 $3,785.92
64577............ Implant neuroelectrodes. N................ ................. H8............... $333.00 109.8976 $4,549.87 $3,785.92
64580............ Implant neuroelectrodes. N................ ................. H8............... $333.00 109.8976 $4,549.87 $3,785.92
64581............ Implant neuroelectrodes. N................ ................. H8............... $510.00 109.8976 $4,549.87 $3,918.67
64585............ Revise/remove Y................ ................. A2............... $333.00 22.4734 $930.42 $482.36
neuroelectrode.
64590............ Insrt/redo pn/gastr N................ ................. H8............... $446.00 269.543 $11,159.35 $10,493.89
stimul.
64595............ Revise/rmv pn/gastr Y................ ................. A2............... $333.00 34.4166 $1,424.88 $605.97
stimul.
64600............ Injection treatment of Y................ ................. A2............... $333.00 14.4879 $599.81 $399.70
nerve.
64605............ Injection treatment of Y................ ................. A2............... $333.00 14.4879 $599.81 $399.70
nerve.
64610............ Injection treatment of Y................ ................. A2............... $333.00 14.4879 $599.81 $399.70
nerve.
64612............ Destroy nerve, face Y................ ................. P3............... ........... 1.6705 $69.16 $69.16
muscle.
64613............ Destroy nerve, neck Y................ ................. P3............... ........... 1.7693 $73.25 $73.25
muscle.
64614............ Destroy nerve, extrem Y................ ................. P3............... ........... 1.9915 $82.45 $82.45
musc.
64620............ Injection treatment of Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
nerve.
64622............ Destr paravertebrl nerve Y................ ................. A2............... $333.00 14.4879 $599.81 $399.70
l/s.
64623............ Destr paravertebral n Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
add-on.
64626............ Destr paravertebrl nerve Y................ ................. A2............... $333.00 14.4879 $599.81 $399.70
c/t.
64627............ Destr paravertebral n Y................ ................. A2............... $333.00 2.3213 $96.10 $273.78
add-on.
64630............ Injection treatment of Y................ ................. A2............... $351.92 7.0546 $292.07 $336.96
nerve.
64640............ Injection treatment of Y................ ................. P3............... ........... 2.7156 $112.43 $112.43
nerve.
64650............ Chemodenerv eccrine Y................ CH............... P3............... ........... 0.65 $26.91 $26.91
glands.
64653............ Chemodenerv eccrine Y................ CH............... P3............... ........... 0.6831 $28.28 $28.28
glands.
64680............ Injection treatment of Y................ ................. A2............... $390.95 14.4879 $599.81 $443.17
nerve.
64681............ Injection treatment of Y................ ................. A2............... $446.00 14.4879 $599.81 $484.45
nerve.
64702............ Revise finger/toe nerve. Y................ ................. A2............... $333.00 18.0518 $747.36 $436.59
64704............ Revise hand/foot nerve.. Y................ ................. A2............... $333.00 18.0518 $747.36 $436.59
64708............ Revise arm/leg nerve.... Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64712............ Revision of sciatic Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
nerve.
64713............ Revision of arm nerve(s) Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64714............ Revise low back nerve(s) Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64716............ Revision of cranial Y................ ................. A2............... $510.00 18.0518 $747.36 $569.34
nerve.
64718............ Revise ulnar nerve at Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
elbow.
[[Page 66987]]
64719............ Revise ulnar nerve at Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
wrist.
64721............ Carpal tunnel surgery... Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64722............ Relieve pressure on Y................ ................. A2............... $333.00 18.0518 $747.36 $436.59
nerve(s).
64726............ Release foot/toe nerve.. Y................ ................. A2............... $333.00 18.0518 $747.36 $436.59
64727............ Internal nerve revision. Y................ ................. A2............... $333.00 18.0518 $747.36 $436.59
64732............ Incision of brow nerve.. Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64734............ Incision of cheek nerve. Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64736............ Incision of chin nerve.. Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64738............ Incision of jaw nerve... Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64740............ Incision of tongue nerve Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64742............ Incision of facial nerve Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64744............ Incise nerve, back of Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
head.
64746............ Incise diaphragm nerve.. Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64761............ Incision of pelvis nerve Y................ ................. G2............... ........... 18.0518 $747.36 $747.36
64763............ Incise hip/thigh nerve.. Y................ ................. G2............... ........... 18.0518 $747.36 $747.36
64766............ Incise hip/thigh nerve.. Y................ ................. G2............... ........... 33.2707 $1,377.44 $1,377.44
64771............ Sever cranial nerve..... Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64772............ Incision of spinal nerve Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64774............ Remove skin nerve lesion Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64776............ Remove digit nerve Y................ ................. A2............... $510.00 18.0518 $747.36 $569.34
lesion.
64778............ Digit nerve surgery add- Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
on.
64782............ Remove limb nerve lesion Y................ ................. A2............... $510.00 18.0518 $747.36 $569.34
64783............ Limb nerve surgery add- Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
on.
64784............ Remove nerve lesion..... Y................ ................. A2............... $510.00 18.0518 $747.36 $569.34
64786............ Remove sciatic nerve Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
lesion.
64787............ Implant nerve end....... Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64788............ Remove skin nerve lesion Y................ ................. A2............... $510.00 18.0518 $747.36 $569.34
64790............ Removal of nerve lesion. Y................ ................. A2............... $510.00 18.0518 $747.36 $569.34
64792............ Removal of nerve lesion. Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
64795............ Biopsy of nerve......... Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
64802............ Remove sympathetic Y................ ................. A2............... $446.00 18.0518 $747.36 $521.34
nerves.
64820............ Remove sympathetic Y................ ................. G2............... ........... 18.0518 $747.36 $747.36
nerves.
64821............ Remove sympathetic Y................ ................. A2............... $630.00 26.3105 $1,089.28 $744.82
nerves.
64822............ Remove sympathetic Y................ ................. G2............... ........... 26.3105 $1,089.28 $1,089.28
nerves.
64823............ Remove sympathetic Y................ ................. G2............... ........... 26.3105 $1,089.28 $1,089.28
nerves.
64831............ Repair of digit nerve... Y................ ................. A2............... $630.00 33.2707 $1,377.44 $816.86
64832............ Repair nerve add-on..... Y................ ................. A2............... $333.00 33.2707 $1,377.44 $594.11
64834............ Repair of hand or foot Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
nerve.
64835............ Repair of hand or foot Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
nerve.
64836............ Repair of hand or foot Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
nerve.
64837............ Repair nerve add-on..... Y................ ................. A2............... $333.00 33.2707 $1,377.44 $594.11
64840............ Repair of leg nerve..... Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
64856............ Repair/transpose nerve.. Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
64857............ Repair arm/leg nerve.... Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
64858............ Repair sciatic nerve.... Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
64859............ Nerve surgery........... Y................ ................. A2............... $333.00 33.2707 $1,377.44 $594.11
64861............ Repair of arm nerves.... Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
64862............ Repair of low back Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
nerves.
64864............ Repair of facial nerve.. Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
64865............ Repair of facial nerve.. Y................ ................. A2............... $630.00 33.2707 $1,377.44 $816.86
64870............ Fusion of facial/other Y................ ................. A2............... $630.00 33.2707 $1,377.44 $816.86
nerve.
64872............ Subsequent repair of Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
nerve.
64874............ Repair & revise nerve Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
add-on.
64876............ Repair nerve/shorten Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
bone.
64885............ Nerve graft, head or Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
neck.
64886............ Nerve graft, head or Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
neck.
64890............ Nerve graft, hand or Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
foot.
64891............ Nerve graft, hand or Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
foot.
64892............ Nerve graft, arm or leg. Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
64893............ Nerve graft, arm or leg. Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
64895............ Nerve graft, hand or Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
foot.
64896............ Nerve graft, hand or Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
foot.
64897............ Nerve graft, arm or leg. Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
64898............ Nerve graft, arm or leg. Y................ ................. A2............... $510.00 33.2707 $1,377.44 $726.86
64901............ Nerve graft add-on...... Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
64902............ Nerve graft add-on...... Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
64905............ Nerve pedicle transfer.. Y................ ................. A2............... $446.00 33.2707 $1,377.44 $678.86
64907............ Nerve pedicle transfer.. Y................ ................. A2............... $333.00 33.2707 $1,377.44 $594.11
64910............ Nerve repair w/allograft Y................ CH............... G2............... ........... 18.0518 $747.36 $747.36
65091............ Revise eye.............. Y................ ................. A2............... $510.00 37.7243 $1,561.82 $772.96
65093............ Revise eye with implant. Y................ ................. A2............... $510.00 37.7243 $1,561.82 $772.96
65101............ Removal of eye.......... Y................ ................. A2............... $510.00 37.7243 $1,561.82 $772.96
65103............ Remove eye/insert Y................ ................. A2............... $510.00 37.7243 $1,561.82 $772.96
implant.
[[Page 66988]]
65105............ Remove eye/attach Y................ ................. A2............... $630.00 37.7243 $1,561.82 $862.96
implant.
65110............ Removal of eye.......... Y................ ................. A2............... $717.00 37.7243 $1,561.82 $928.21
65112............ Remove eye/revise socket Y................ ................. A2............... $995.00 37.7243 $1,561.82 $1,136.71
65114............ Remove eye/revise socket Y................ ................. A2............... $995.00 37.7243 $1,561.82 $1,136.71
65125............ Revise ocular implant... Y................ ................. G2............... ........... 18.7307 $775.47 $775.47
65130............ Insert ocular implant... Y................ ................. A2............... $510.00 24.3077 $1,006.36 $634.09
65135............ Insert ocular implant... Y................ ................. A2............... $446.00 24.3077 $1,006.36 $586.09
65140............ Attach ocular implant... Y................ ................. A2............... $510.00 37.7243 $1,561.82 $772.96
65150............ Revise ocular implant... Y................ ................. A2............... $446.00 24.3077 $1,006.36 $586.09
65155............ Reinsert ocular implant. Y................ ................. A2............... $510.00 37.7243 $1,561.82 $772.96
65175............ Removal of ocular Y................ ................. A2............... $333.00 18.7307 $775.47 $443.62
implant.
65205............ Remove foreign body from N................ ................. P3............... ........... 0.4937 $20.44 $20.44
eye.
65210............ Remove foreign body from N................ ................. P3............... ........... 0.6253 $25.89 $25.89
eye.
65220............ Remove foreign body from N................ ................. G2............... ........... 0.8696 $36.00 $36.00
eye.
65222............ Remove foreign body from N................ ................. P3............... ........... 0.6831 $28.28 $28.28
eye.
65235............ Remove foreign body from Y................ ................. A2............... $446.00 16.171 $669.50 $501.88
eye.
65260............ Remove foreign body from Y................ ................. A2............... $510.00 18.235 $754.95 $571.24
eye.
65265............ Remove foreign body from Y................ ................. A2............... $630.00 27.845 $1,152.81 $760.70
eye.
65270............ Repair of eye wound..... Y................ ................. A2............... $446.00 18.7307 $775.47 $528.37
65272............ Repair of eye wound..... Y................ ................. A2............... $446.00 23.1758 $959.50 $574.38
65275............ Repair of eye wound..... Y................ ................. A2............... $630.00 23.1758 $959.50 $712.38
65280............ Repair of eye wound..... Y................ ................. A2............... $630.00 18.235 $754.95 $661.24
65285............ Repair of eye wound..... Y................ ................. A2............... $630.00 37.2078 $1,540.44 $857.61
65286............ Repair of eye wound..... Y................ ................. P2............... ........... 5.1169 $211.84 $211.84
65290............ Repair of eye socket Y................ ................. A2............... $510.00 24.1291 $998.97 $632.24
wound.
65400............ Removal of eye lesion... Y................ ................. A2............... $333.00 16.171 $669.50 $417.13
65410............ Biopsy of cornea........ Y................ ................. A2............... $446.00 16.171 $669.50 $501.88
65420............ Removal of eye lesion... Y................ ................. A2............... $446.00 16.171 $669.50 $501.88
65426............ Removal of eye lesion... Y................ ................. A2............... $717.00 23.1758 $959.50 $777.63
65430............ Corneal smear........... N................ CH............... P2............... ........... 0.8696 $36.00 $36.00
65435............ Curette/treat cornea.... Y................ ................. P3............... ........... 0.7652 $31.68 $31.68
65436............ Curette/treat cornea.... Y................ ................. G2............... ........... 16.171 $669.50 $669.50
65450............ Treatment of corneal N................ ................. G2............... ........... 2.179 $90.21 $90.21
lesion.
65600............ Revision of cornea...... Y................ ................. P3............... ........... 3.8758 $160.46 $160.46
65710............ Corneal transplant...... Y................ ................. A2............... $995.00 37.4896 $1,552.11 $1,134.28
65730............ Corneal transplant...... Y................ ................. A2............... $995.00 37.4896 $1,552.11 $1,134.28
65750............ Corneal transplant...... Y................ ................. A2............... $995.00 37.4896 $1,552.11 $1,134.28
65755............ Corneal transplant...... Y................ ................. A2............... $995.00 37.4896 $1,552.11 $1,134.28
65770............ Revise cornea with Y................ ................. A2............... $995.00 84.8039 $3,510.97 $1,623.99
implant.
65772............ Correction of Y................ ................. A2............... $630.00 16.171 $669.50 $639.88
astigmatism.
65775............ Correction of Y................ ................. A2............... $630.00 16.171 $669.50 $639.88
astigmatism.
65780............ Ocular reconst, Y................ ................. A2............... $717.00 37.4896 $1,552.11 $925.78
transplant.
65781............ Ocular reconst, Y................ ................. A2............... $717.00 37.4896 $1,552.11 $925.78
transplant.
65782............ Ocular reconst, Y................ ................. A2............... $717.00 37.4896 $1,552.11 $925.78
transplant.
65800............ Drainage of eye......... Y................ ................. A2............... $333.00 16.171 $669.50 $417.13
65805............ Drainage of eye......... Y................ ................. A2............... $333.00 16.171 $669.50 $417.13
65810............ Drainage of eye......... Y................ ................. A2............... $510.00 23.1758 $959.50 $622.38
65815............ Drainage of eye......... Y................ ................. A2............... $446.00 23.1758 $959.50 $574.38
65820............ Relieve inner eye Y................ ................. A2............... $333.00 5.1169 $211.84 $302.71
pressure.
65850............ Incision of eye......... Y................ ................. A2............... $630.00 23.1758 $959.50 $712.38
65855............ Laser surgery of eye.... Y................ ................. P3............... ........... 3.2011 $132.53 $132.53
65860............ Incise inner eye Y................ ................. P3............... ........... 2.9953 $124.01 $124.01
adhesions.
65865............ Incise inner eye Y................ ................. A2............... $333.00 16.171 $669.50 $417.13
adhesions.
65870............ Incise inner eye Y................ ................. A2............... $630.00 23.1758 $959.50 $712.38
adhesions.
65875............ Incise inner eye Y................ ................. A2............... $630.00 23.1758 $959.50 $712.38
adhesions.
65880............ Incise inner eye Y................ ................. A2............... $630.00 16.171 $669.50 $639.88
adhesions.
65900............ Remove eye lesion....... Y................ ................. A2............... $717.00 16.171 $669.50 $705.13
65920............ Remove implant of eye... Y................ ................. A2............... $995.00 23.1758 $959.50 $986.13
65930............ Remove blood clot from Y................ ................. A2............... $717.00 23.1758 $959.50 $777.63
eye.
66020............ Injection treatment of Y................ ................. A2............... $333.00 16.171 $669.50 $417.13
eye.
66030............ Injection treatment of Y................ ................. A2............... $333.00 5.1169 $211.84 $302.71
eye.
66130............ Remove eye lesion....... Y................ ................. A2............... $995.00 23.1758 $959.50 $986.13
66150............ Glaucoma surgery........ Y................ ................. A2............... $630.00 23.1758 $959.50 $712.38
66155............ Glaucoma surgery........ Y................ ................. A2............... $630.00 23.1758 $959.50 $712.38
66160............ Glaucoma surgery........ Y................ ................. A2............... $446.00 23.1758 $959.50 $574.38
66165............ Glaucoma surgery........ Y................ ................. A2............... $630.00 23.1758 $959.50 $712.38
66170............ Glaucoma surgery........ Y................ ................. A2............... $630.00 23.1758 $959.50 $712.38
66172............ Incision of eye......... Y................ ................. A2............... $630.00 23.1758 $959.50 $712.38
66180............ Implant eye shunt....... Y................ ................. A2............... $717.00 39.7101 $1,644.04 $948.76
66185............ Revise eye shunt........ Y................ ................. A2............... $446.00 39.7101 $1,644.04 $745.51
66220............ Repair eye lesion....... Y................ ................. A2............... $510.00 37.2078 $1,540.44 $767.61
66225............ Repair/graft eye lesion. Y................ ................. A2............... $630.00 39.7101 $1,644.04 $883.51
66250............ Follow-up surgery of eye Y................ ................. A2............... $446.00 16.171 $669.50 $501.88
[[Page 66989]]
66500............ Incision of iris........ Y................ ................. A2............... $333.00 5.1169 $211.84 $302.71
66505............ Incision of iris........ Y................ ................. A2............... $333.00 5.1169 $211.84 $302.71
66600............ Remove iris and lesion.. Y................ ................. A2............... $510.00 23.1758 $959.50 $622.38
66605............ Removal of iris......... Y................ ................. A2............... $510.00 23.1758 $959.50 $622.38
66625............ Removal of iris......... Y................ ................. A2............... $372.94 5.1169 $211.84 $332.67
66630............ Removal of iris......... Y................ ................. A2............... $510.00 23.1758 $959.50 $622.38
66635............ Removal of iris......... Y................ ................. A2............... $510.00 23.1758 $959.50 $622.38
66680............ Repair iris & ciliary Y................ ................. A2............... $510.00 23.1758 $959.50 $622.38
body.
66682............ Repair iris & ciliary Y................ ................. A2............... $446.00 23.1758 $959.50 $574.38
body.
66700............ Destruction, ciliary Y................ ................. A2............... $446.00 16.171 $669.50 $501.88
body.
66710............ Ciliary transsleral Y................ ................. A2............... $446.00 16.171 $669.50 $501.88
therapy.
66711............ Ciliary endoscopic Y................ ................. A2............... $446.00 16.171 $669.50 $501.88
ablation.
66720............ Destruction, ciliary Y................ ................. A2............... $446.00 16.171 $669.50 $501.88
body.
66740............ Destruction, ciliary Y................ ................. A2............... $446.00 23.1758 $959.50 $574.38
body.
66761............ Revision of iris........ Y................ ................. P3............... ........... 4.3612 $180.56 $180.56
66762............ Revision of iris........ Y................ ................. P3............... ........... 4.419 $182.95 $182.95
66770............ Removal of inner eye Y................ ................. P3............... ........... 4.7728 $197.60 $197.60
lesion.
66820............ Incision, secondary Y................ ................. G2............... ........... 5.1169 $211.84 $211.84
cataract.
66821............ After cataract laser Y................ ................. A2............... $312.50 5.2001 $215.29 $288.20
surgery.
66825............ Reposition intraocular Y................ ................. A2............... $630.00 23.1758 $959.50 $712.38
lens.
66830............ Removal of lens lesion.. Y................ ................. A2............... $372.94 5.1169 $211.84 $332.67
66840............ Removal of lens material Y................ ................. A2............... $630.00 14.9171 $617.58 $626.90
66850............ Removal of lens material Y................ ................. A2............... $995.00 28.7035 $1,188.35 $1,043.34
66852............ Removal of lens material Y................ ................. A2............... $630.00 28.7035 $1,188.35 $769.59
66920............ Extraction of lens...... Y................ ................. A2............... $630.00 28.7035 $1,188.35 $769.59
66930............ Extraction of lens...... Y................ ................. A2............... $717.00 28.7035 $1,188.35 $834.84
66940............ Extraction of lens...... Y................ ................. A2............... $717.00 14.9171 $617.58 $692.15
66982............ Cataract surgery, Y................ ................. A2............... $973.00 23.8649 $988.03 $976.76
complex.
66983............ Cataract surg w/iol, 1 Y................ ................. A2............... $973.00 23.8649 $988.03 $976.76
stage.
66984............ Cataract surg w/iol, 1 Y................ ................. A2............... $973.00 23.8649 $988.03 $976.76
stage.
66985............ Insert lens prosthesis.. Y................ ................. A2............... $826.00 23.8649 $988.03 $866.51
66986............ Exchange lens prosthesis Y................ ................. A2............... $826.00 23.8649 $988.03 $866.51
66990............ Ophthalmic endoscope add- N................ ................. N1............... ........... ........... ........... ...........
on.
67005............ Partial removal of eye Y................ ................. A2............... $630.00 27.845 $1,152.81 $760.70
fluid.
67010............ Partial removal of eye Y................ ................. A2............... $630.00 27.845 $1,152.81 $760.70
fluid.
67015............ Release of eye fluid.... Y................ ................. A2............... $333.00 27.845 $1,152.81 $537.95
67025............ Replace eye fluid....... Y................ ................. A2............... $333.00 27.845 $1,152.81 $537.95
67027............ Implant eye drug system. Y................ ................. A2............... $630.00 37.2078 $1,540.44 $857.61
67028............ Injection eye drug...... N................ ................. P3............... ........... 1.9915 $82.45 $82.45
67030............ Incise inner eye strands Y................ ................. A2............... $333.00 18.235 $754.95 $438.49
67031............ Laser surgery, eye Y................ ................. A2............... $312.50 5.2001 $215.29 $288.20
strands.
67036............ Removal of inner eye Y................ ................. A2............... $630.00 37.2078 $1,540.44 $857.61
fluid.
67038............ Strip retinal membrane.. N................ CH............... D5............... ........... ........... ........... ...........
67039............ Laser treatment of Y................ ................. A2............... $995.00 37.2078 $1,540.44 $1,131.36
retina.
67040............ Laser treatment of Y................ ................. A2............... $995.00 37.2078 $1,540.44 $1,131.36
retina.
67041............ Vit for macular pucker.. Y................ NI............... G2............... ........... 37.2078 $1,540.44 $1,540.44
67042............ Vit for macular hole.... Y................ NI............... G2............... ........... 37.2078 $1,540.44 $1,540.44
67043............ Vit for membrane dissect Y................ NI............... G2............... ........... 37.2078 $1,540.44 $1,540.44
67101............ Repair detached retina.. Y................ ................. P3............... ........... 7.2414 $299.80 $299.80
67105............ Repair detached retina.. Y................ ................. P2............... ........... 5.2001 $215.29 $215.29
67107............ Repair detached retina.. Y................ ................. A2............... $717.00 37.2078 $1,540.44 $922.86
67108............ Repair detached retina.. Y................ ................. A2............... $995.00 37.2078 $1,540.44 $1,131.36
67110............ Repair detached retina.. Y................ ................. P3............... ........... 7.8749 $326.03 $326.03
67112............ Rerepair detached retina Y................ ................. A2............... $995.00 37.2078 $1,540.44 $1,131.36
67113............ Repair retinal detach, Y................ NI............... G2............... ........... 37.2078 $1,540.44 $1,540.44
cplx.
67115............ Release encircling Y................ ................. A2............... $446.00 18.235 $754.95 $523.24
material.
67120............ Remove eye implant Y................ ................. A2............... $446.00 18.235 $754.95 $523.24
material.
67121............ Remove eye implant Y................ ................. A2............... $446.00 27.845 $1,152.81 $622.70
material.
67141............ Treatment of retina..... Y................ ................. A2............... $241.77 4.1331 $171.11 $224.11
67145............ Treatment of retina..... Y................ ................. P3............... ........... 4.5506 $188.40 $188.40
67208............ Treatment of retinal Y................ ................. P3............... ........... 4.8385 $200.32 $200.32
lesion.
67210............ Treatment of retinal Y................ CH............... P3............... ........... 5.1349 $212.59 $212.59
lesion.
67218............ Treatment of retinal Y................ ................. A2............... $717.00 18.235 $754.95 $726.49
lesion.
67220............ Treatment of choroid Y................ ................. P2............... ........... 4.1331 $171.11 $171.11
lesion.
67221............ Ocular photodynamic ther Y................ ................. P3............... ........... 2.9789 $123.33 $123.33
67225............ Eye photodynamic ther Y................ ................. P3............... ........... 0.1976 $8.18 $8.18
add-on.
67227............ Treatment of retinal Y................ ................. A2............... $333.00 27.845 $1,152.81 $537.95
lesion.
67228............ Treatment of retinal Y................ ................. P2............... ........... 5.2001 $215.29 $215.29
lesion.
67229*........... Tr retinal les preterm Y................ NI............... R2............... ........... 5.2001 $215.29 $215.29
inf.
67250............ Reinforce eye wall...... Y................ ................. A2............... $510.00 18.7307 $775.47 $576.37
67255............ Reinforce/graft eye wall Y................ ................. A2............... $510.00 27.845 $1,152.81 $670.70
67311............ Revise eye muscle....... Y................ ................. A2............... $510.00 24.1291 $998.97 $632.24
67312............ Revise two eye muscles.. Y................ ................. A2............... $630.00 24.1291 $998.97 $722.24
[[Page 66990]]
67314............ Revise eye muscle....... Y................ ................. A2............... $630.00 24.1291 $998.97 $722.24
67316............ Revise two eye muscles.. Y................ ................. A2............... $630.00 24.1291 $998.97 $722.24
67318............ Revise eye muscle(s).... Y................ ................. A2............... $630.00 24.1291 $998.97 $722.24
67320............ Revise eye muscle(s) add- Y................ ................. A2............... $630.00 24.1291 $998.97 $722.24
on.
67331............ Eye surgery follow-up Y................ ................. A2............... $630.00 24.1291 $998.97 $722.24
add-on.
67332............ Rerevise eye muscles add- Y................ ................. A2............... $630.00 24.1291 $998.97 $722.24
on.
67334............ Revise eye muscle w/ Y................ ................. A2............... $630.00 24.1291 $998.97 $722.24
suture.
67335............ Eye suture during Y................ ................. A2............... $630.00 24.1291 $998.97 $722.24
surgery.
67340............ Revise eye muscle add-on Y................ ................. A2............... $630.00 24.1291 $998.97 $722.24
67343............ Release eye tissue...... Y................ ................. A2............... $995.00 24.1291 $998.97 $995.99
67345............ Destroy nerve of eye Y................ ................. P3............... ........... 1.9584 $81.08 $81.08
muscle.
67346............ Biopsy, eye muscle...... Y................ ................. A2............... $333.00 13.7453 $569.07 $392.02
67400............ Explore/biopsy eye Y................ ................. A2............... $510.00 24.3077 $1,006.36 $634.09
socket.
67405............ Explore/drain eye socket Y................ ................. A2............... $630.00 24.3077 $1,006.36 $724.09
67412............ Explore/treat eye socket Y................ ................. A2............... $717.00 24.3077 $1,006.36 $789.34
67413............ Explore/treat eye socket Y................ ................. A2............... $717.00 24.3077 $1,006.36 $789.34
67414............ Explr/decompress eye Y................ ................. G2............... ........... 37.7243 $1,561.82 $1,561.82
socket.
67415............ Aspiration, orbital Y................ ................. A2............... $333.00 18.7307 $775.47 $443.62
contents.
67420............ Explore/treat eye socket Y................ ................. A2............... $717.00 37.7243 $1,561.82 $928.21
67430............ Explore/treat eye socket Y................ ................. A2............... $717.00 37.7243 $1,561.82 $928.21
67440............ Explore/drain eye socket Y................ ................. A2............... $717.00 37.7243 $1,561.82 $928.21
67445............ Explr/decompress eye Y................ ................. A2............... $717.00 37.7243 $1,561.82 $928.21
socket.
67450............ Explore/biopsy eye Y................ ................. A2............... $717.00 37.7243 $1,561.82 $928.21
socket.
67500............ Inject/treat eye socket. N................ ................. G2............... ........... 2.179 $90.21 $90.21
67505............ Inject/treat eye socket. Y................ ................. G2............... ........... 2.9022 $120.15 $120.15
67515............ Inject/treat eye socket. Y................ ................. P3............... ........... 0.5596 $23.17 $23.17
67550............ Insert eye socket Y................ ................. A2............... $630.00 37.7243 $1,561.82 $862.96
implant.
67560............ Revise eye socket Y................ ................. A2............... $446.00 24.3077 $1,006.36 $586.09
implant.
67570............ Decompress optic nerve.. Y................ ................. A2............... $630.00 37.7243 $1,561.82 $862.96
67700............ Drainage of eyelid Y................ ................. P2............... ........... 2.9022 $120.15 $120.15
abscess.
67710............ Incision of eyelid...... Y................ ................. P3............... ........... 3.7277 $154.33 $154.33
67715............ Incision of eyelid fold. Y................ ................. A2............... $333.00 18.7307 $775.47 $443.62
67800............ Remove eyelid lesion.... Y................ ................. P3............... ........... 1.2343 $51.10 $51.10
67801............ Remove eyelid lesions... Y................ ................. P3............... ........... 1.4975 $62.00 $62.00
67805............ Remove eyelid lesions... Y................ ................. P3............... ........... 1.9338 $80.06 $80.06
67808............ Remove eyelid lesion(s). Y................ ................. A2............... $446.00 18.7307 $775.47 $528.37
67810............ Biopsy of eyelid........ Y................ ................. P2............... ........... 2.9022 $120.15 $120.15
67820............ Revise eyelashes........ N................ ................. P3............... ........... 0.428 $17.72 $17.72
67825............ Revise eyelashes........ Y................ ................. P3............... ........... 1.292 $53.49 $53.49
67830............ Revise eyelashes........ Y................ ................. A2............... $446.00 7.2847 $301.59 $409.90
67835............ Revise eyelashes........ Y................ ................. A2............... $446.00 18.7307 $775.47 $528.37
67840............ Remove eyelid lesion.... Y................ ................. P3............... ........... 3.8593 $159.78 $159.78
67850............ Treat eyelid lesion..... Y................ ................. P3............... ........... 2.7403 $113.45 $113.45
67875............ Closure of eyelid by Y................ ................. G2............... ........... 7.2847 $301.59 $301.59
suture.
67880............ Revision of eyelid...... Y................ ................. A2............... $510.00 16.171 $669.50 $549.88
67882............ Revision of eyelid...... Y................ ................. A2............... $510.00 18.7307 $775.47 $576.37
67900............ Repair brow defect...... Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
67901............ Repair eyelid defect.... Y................ ................. A2............... $717.00 18.7307 $775.47 $731.62
67902............ Repair eyelid defect.... Y................ ................. A2............... $717.00 18.7307 $775.47 $731.62
67903............ Repair eyelid defect.... Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
67904............ Repair eyelid defect.... Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
67906............ Repair eyelid defect.... Y................ ................. A2............... $717.00 18.7307 $775.47 $731.62
67908............ Repair eyelid defect.... Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
67909............ Revise eyelid defect.... Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
67911............ Revise eyelid defect.... Y................ ................. A2............... $510.00 18.7307 $775.47 $576.37
67912............ Correction eyelid w/ Y................ ................. A2............... $510.00 18.7307 $775.47 $576.37
implant.
67914............ Repair eyelid defect.... Y................ ................. A2............... $510.00 18.7307 $775.47 $576.37
67915............ Repair eyelid defect.... Y................ ................. P3............... ........... 4.2378 $175.45 $175.45
67916............ Repair eyelid defect.... Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
67917............ Repair eyelid defect.... Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
67921............ Repair eyelid defect.... Y................ ................. A2............... $510.00 18.7307 $775.47 $576.37
67922............ Repair eyelid defect.... Y................ ................. P3............... ........... 4.139 $171.36 $171.36
67923............ Repair eyelid defect.... Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
67924............ Repair eyelid defect.... Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
67930............ Repair eyelid wound..... Y................ ................. P3............... ........... 4.1472 $171.70 $171.70
67935............ Repair eyelid wound..... Y................ ................. A2............... $446.00 18.7307 $775.47 $528.37
67938............ Remove eyelid foreign N................ ................. P2............... ........... 2.179 $90.21 $90.21
body.
67950............ Revision of eyelid...... Y................ ................. A2............... $446.00 18.7307 $775.47 $528.37
67961............ Revision of eyelid...... Y................ ................. A2............... $510.00 18.7307 $775.47 $576.37
67966............ Revision of eyelid...... Y................ ................. A2............... $510.00 18.7307 $775.47 $576.37
67971............ Reconstruction of eyelid Y................ ................. A2............... $510.00 24.3077 $1,006.36 $634.09
67973............ Reconstruction of eyelid Y................ ................. A2............... $510.00 24.3077 $1,006.36 $634.09
67974............ Reconstruction of eyelid Y................ ................. A2............... $510.00 24.3077 $1,006.36 $634.09
[[Page 66991]]
67975............ Reconstruction of eyelid Y................ ................. A2............... $510.00 18.7307 $775.47 $576.37
68020............ Incise/drain eyelid Y................ ................. P3............... ........... 1.0862 $44.97 $44.97
lining.
68040............ Treatment of eyelid N................ ................. P3............... ........... 0.5348 $22.14 $22.14
lesions.
68100............ Biopsy of eyelid lining. Y................ ................. P3............... ........... 2.3041 $95.39 $95.39
68110............ Remove eyelid lining Y................ ................. P3............... ........... 2.9458 $121.96 $121.96
lesion.
68115............ Remove eyelid lining Y................ ................. A2............... $446.00 18.7307 $775.47 $528.37
lesion.
68130............ Remove eyelid lining Y................ ................. A2............... $446.00 16.171 $669.50 $501.88
lesion.
68135............ Remove eyelid lining Y................ ................. P3............... ........... 1.399 $57.92 $57.92
lesion.
68200............ Treat eyelid by N................ ................. P3............... ........... 0.4031 $16.69 $16.69
injection.
68320............ Revise/graft eyelid Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
lining.
68325............ Revise/graft eyelid Y................ ................. A2............... $630.00 24.3077 $1,006.36 $724.09
lining.
68326............ Revise/graft eyelid Y................ ................. A2............... $630.00 24.3077 $1,006.36 $724.09
lining.
68328............ Revise/graft eyelid Y................ ................. A2............... $630.00 24.3077 $1,006.36 $724.09
lining.
68330............ Revise eyelid lining.... Y................ ................. A2............... $630.00 23.1758 $959.50 $712.38
68335............ Revise/graft eyelid Y................ ................. A2............... $630.00 24.3077 $1,006.36 $724.09
lining.
68340............ Separate eyelid Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
adhesions.
68360............ Revise eyelid lining.... Y................ ................. A2............... $446.00 23.1758 $959.50 $574.38
68362............ Revise eyelid lining.... Y................ ................. A2............... $446.00 23.1758 $959.50 $574.38
68371............ Harvest eye tissue, Y................ ................. A2............... $446.00 16.171 $669.50 $501.88
alograft.
68400............ Incise/drain tear gland. Y................ ................. P2............... ........... 2.9022 $120.15 $120.15
68420............ Incise/drain tear sac... Y................ ................. P3............... ........... 4.4354 $183.63 $183.63
68440............ Incise tear duct opening Y................ ................. P3............... ........... 1.3741 $56.89 $56.89
68500............ Removal of tear gland... Y................ ................. A2............... $510.00 24.3077 $1,006.36 $634.09
68505............ Partial removal, tear Y................ ................. A2............... $510.00 24.3077 $1,006.36 $634.09
gland.
68510............ Biopsy of tear gland.... Y................ ................. A2............... $333.00 18.7307 $775.47 $443.62
68520............ Removal of tear sac..... Y................ ................. A2............... $510.00 24.3077 $1,006.36 $634.09
68525............ Biopsy of tear sac...... Y................ ................. A2............... $333.00 18.7307 $775.47 $443.62
68530............ Clearance of tear duct.. Y................ ................. P3............... ........... 5.6615 $234.39 $234.39
68540............ Remove tear gland lesion Y................ ................. A2............... $510.00 24.3077 $1,006.36 $634.09
68550............ Remove tear gland lesion Y................ ................. A2............... $510.00 24.3077 $1,006.36 $634.09
68700............ Repair tear ducts....... Y................ ................. A2............... $446.00 24.3077 $1,006.36 $586.09
68705............ Revise tear duct opening Y................ ................. P2............... ........... 2.9022 $120.15 $120.15
68720............ Create tear sac drain... Y................ ................. A2............... $630.00 24.3077 $1,006.36 $724.09
68745............ Create tear duct drain.. Y................ ................. A2............... $630.00 24.3077 $1,006.36 $724.09
68750............ Create tear duct drain.. Y................ ................. A2............... $630.00 24.3077 $1,006.36 $724.09
68760............ Close tear duct opening. N................ ................. P2............... ........... 2.179 $90.21 $90.21
68761............ Close tear duct opening. N................ ................. P3............... ........... 1.6869 $69.84 $69.84
68770............ Close tear system Y................ ................. A2............... $630.00 18.7307 $775.47 $666.37
fistula.
68801............ Dilate tear duct opening N................ ................. P2............... ........... 0.8696 $36.00 $36.00
68810............ Probe nasolacrimal duct. N................ ................. A2............... $131.86 2.179 $90.21 $121.45
68811............ Probe nasolacrimal duct. Y................ ................. A2............... $446.00 18.7307 $775.47 $528.37
68815............ Probe nasolacrimal duct. Y................ ................. A2............... $446.00 18.7307 $775.47 $528.37
68816*........... Probe nl duct w/balloon. Y................ NI............... P3............... ........... 10.4754 $433.69 $433.69
68840............ Explore/irrigate tear N................ CH............... P3............... ........... 1.2756 $52.81 $52.81
ducts.
68850............ Injection for tear sac x- N................ ................. N1............... ........... ........... ........... ...........
ray.
69000............ Drain external ear Y................ ................. P2............... ........... 1.4066 $58.23 $58.23
lesion.
69005............ Drain external ear Y................ ................. P3............... ........... 2.4357 $100.84 $100.84
lesion.
69020............ Drain outer ear canal Y................ ................. P2............... ........... 1.4066 $58.23 $58.23
lesion.
69100............ Biopsy of external ear.. Y................ ................. P3............... ........... 1.4647 $60.64 $60.64
69105............ Biopsy of external ear Y................ ................. P3............... ........... 2.049 $84.83 $84.83
canal.
69110............ Remove external ear, Y................ ................. A2............... $333.00 16.1001 $666.56 $416.39
partial.
69120............ Removal of external ear. Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
69140............ Remove ear canal Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
lesion(s).
69145............ Remove ear canal Y................ ................. A2............... $446.00 16.1001 $666.56 $501.14
lesion(s).
69150............ Extensive ear canal Y................ ................. A2............... $464.15 7.4474 $308.33 $425.20
surgery.
69200............ Clear outer ear canal... N................ ................. P2............... ........... 0.631 $26.12 $26.12
69205............ Clear outer ear canal... Y................ ................. A2............... $333.00 21.1098 $873.97 $468.24
69210............ Remove impacted ear wax. N................ ................. P3............... ........... 0.4937 $20.44 $20.44
69220............ Clean out mastoid cavity Y................ ................. P2............... ........... 0.793 $32.83 $32.83
69222............ Clean out mastoid cavity Y................ ................. P3............... ........... 3.2176 $133.21 $133.21
69300............ Revise external ear..... Y................ ................. A2............... $510.00 23.9765 $992.65 $630.66
69310............ Rebuild outer ear canal. Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
69320............ Rebuild outer ear canal. Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69400............ Inflate middle ear canal Y................ ................. P3............... ........... 2.049 $84.83 $84.83
69401............ Inflate middle ear canal Y................ ................. P3............... ........... 1.1355 $47.01 $47.01
69405............ Catheterize middle ear Y................ ................. P3............... ........... 2.9458 $121.96 $121.96
canal.
69420............ Incision of eardrum..... Y................ ................. P2............... ........... 2.5002 $103.51 $103.51
69421............ Incision of eardrum..... Y................ ................. A2............... $510.00 16.3288 $676.03 $551.51
69424............ Remove ventilating tube. Y................ ................. P3............... ........... 1.8596 $76.99 $76.99
69433............ Create eardrum opening.. Y................ ................. P3............... ........... 2.6333 $109.02 $109.02
69436............ Create eardrum opening.. Y................ ................. A2............... $510.00 16.3288 $676.03 $551.51
69440............ Exploration of middle Y................ ................. A2............... $510.00 23.9765 $992.65 $630.66
ear.
69450............ Eardrum revision........ Y................ ................. A2............... $333.00 39.8776 $1,650.97 $662.49
[[Page 66992]]
69501............ Mastoidectomy........... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69502............ Mastoidectomy........... Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
69505............ Remove mastoid Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
structures.
69511............ Extensive mastoid Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
surgery.
69530............ Extensive mastoid Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
surgery.
69540............ Remove ear lesion....... Y................ ................. P3............... ........... 3.1434 $130.14 $130.14
69550............ Remove ear lesion....... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
69552............ Remove ear lesion....... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69601............ Mastoid surgery revision Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69602............ Mastoid surgery revision Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69603............ Mastoid surgery revision Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69604............ Mastoid surgery revision Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69605............ Mastoid surgery revision Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69610............ Repair of eardrum....... Y................ ................. P3............... ........... 4.3038 $178.18 $178.18
69620............ Repair of eardrum....... Y................ ................. A2............... $446.00 23.9765 $992.65 $582.66
69631............ Repair eardrum Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
structures.
69632............ Rebuild eardrum Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
structures.
69633............ Rebuild eardrum Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
structures.
69635............ Repair eardrum Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
structures.
69636............ Rebuild eardrum Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
structures.
69637............ Rebuild eardrum Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
structures.
69641............ Revise middle ear & Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
mastoid.
69642............ Revise middle ear & Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
mastoid.
69643............ Revise middle ear & Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
mastoid.
69644............ Revise middle ear & Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
mastoid.
69645............ Revise middle ear & Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
mastoid.
69646............ Revise middle ear & Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
mastoid.
69650............ Release middle ear bone. Y................ ................. A2............... $995.00 23.9765 $992.65 $994.41
69660............ Revise middle ear bone.. Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
69661............ Revise middle ear bone.. Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
69662............ Revise middle ear bone.. Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
69666............ Repair middle ear Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
structures.
69667............ Repair middle ear Y................ ................. A2............... $630.00 39.8776 $1,650.97 $885.24
structures.
69670............ Remove mastoid air cells Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
69676............ Remove middle ear nerve. Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
69700............ Close mastoid fistula... Y................ ................. A2............... $510.00 39.8776 $1,650.97 $795.24
69711............ Remove/repair hearing Y................ ................. A2............... $333.00 39.8776 $1,650.97 $662.49
aid.
69714............ Implant temple bone w/ Y................ ................. A2............... $1,339.00 39.8776 $1,650.97 $1,416.99
stimul.
69715............ Temple bne implnt w/ Y................ ................. A2............... $1,339.00 39.8776 $1,650.97 $1,416.99
stimulat.
69717............ Temple bone implant Y................ ................. A2............... $1,339.00 39.8776 $1,650.97 $1,416.99
revision.
69718............ Revise temple bone Y................ ................. A2............... $1,339.00 39.8776 $1,650.97 $1,416.99
implant.
69720............ Release facial nerve.... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
69740............ Repair facial nerve..... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
69745............ Repair facial nerve..... Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
69801............ Incise inner ear........ Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
69802............ Incise inner ear........ Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69805............ Explore inner ear....... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69806............ Explore inner ear....... Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69820............ Establish inner ear Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
window.
69840............ Revise inner ear window. Y................ ................. A2............... $717.00 39.8776 $1,650.97 $950.49
69905............ Remove inner ear........ Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69910............ Remove inner ear & Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
mastoid.
69915............ Incise inner ear nerve.. Y................ ................. A2............... $995.00 39.8776 $1,650.97 $1,158.99
69930............ Implant cochlear device. Y................ ................. H8............... $995.00 568.8394 $23,550.52 $22,213.76
69990............ Microsurgery add-on..... N................ ................. N1............... ........... ........... ........... ...........
C9716............ Radiofrequency energy to Y................ ................. G2............... ........... 30.1606 $1,248.68 $1,248.68
anu.
C9724............ EPS gast cardia plic.... Y................ ................. G2............... ........... 25.3233 $1,048.41 $1,048.41
C9725............ Place endorectal app.... N................ ................. G2............... ........... 8.6351 $357.50 $357.50
C9726............ Rxt breast appl place/ N................ ................. G2............... ........... 10.2051 $422.50 $422.50
remov.
C9727............ Insert palate implants.. N................ ................. G2............... ........... 13.3451 $552.50 $552.50
C9728............ Place device/marker, non Y................ CH............... R2............... ........... 3.0469 $126.14 $126.14
pro.
G0104............ CA screen;flexi N................ ................. P3............... ........... 1.9748 $81.76 $81.76
sigmoidscope.
G0105............ Colorectal scrn; hi risk Y................ ................. A2............... $446.00 7.8504 $325.01 $415.75
ind.
G0121............ Colon ca scrn not hi rsk Y................ ................. A2............... $446.00 7.8504 $325.01 $415.75
ind.
G0127............ Trim nail(s)............ Y................ ................. P3............... ........... 0.2633 $10.90 $10.90
G0186............ Dstry eye lesn,fdr vssl Y................ ................. R2............... ........... 4.1331 $171.11 $171.11
tech.
G0247............ Routine footcare pt w Y................ ................. P3............... ........... 0.4937 $20.44 $20.44
lops.
G0259............ Inject for sacroiliac N................ ................. N1............... ........... ........... ........... ...........
joint.
G0260............ Inj for sacroiliac jt Y................ ................. A2............... $333.00 7.0546 $292.07 $322.77
anesth.
G0268............ Removal of impacted wax N................ CH............... N1............... ........... ........... ........... ...........
md.
G0269............ Occlusive device in vein N................ ................. N1............... ........... ........... ........... ...........
art.
G0289............ Arthro, loose body + N................ ................. N1............... ........... ........... ........... ...........
chondro.
G0364............ Bone marrow aspirate Y................ ................. P3............... ........... 0.1234 $5.11 $5.11
&biopsy.
[[Page 66993]]
G0392............ AV fistula or graft Y................ ................. A2............... $1,339.00 45.3845 $1,878.96 $1,473.99
arterial.
G0393............ AV fistula or graft Y................ ................. A2............... $1,339.00 45.3845 $1,878.96 $1,473.99
venous.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note: The Medicare program payment is 80 percent of the total payment amount and beneficiary coinsurance is 20 percent of the total payment amount,
except for screening flexible sigmoidoscopies and screening colonoscopies for which the program payment is 75 percent and the beneficiary coinsurance
is 25 percent.
* Refers to HCPCS codes designated as ``office-based,'' whose designation as office-based is temporary because we have insufficient claims data. We will
reconsider this designation when new claims data become available.
Federal Register / Vol. 72, No. 227 / Tuesday, November 27, 2007 /
Rules and Regulations
Addendum B.--OPPS Payment by HCPCS Code for CY 2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
National Minimum
HCPCS code Short descriptor CI SI APC Relative Payment unadjusted unadjusted
weight rate copayment copayment
--------------------------------------------------------------------------------------------------------------------------------------------------------
0001F.............. Heart failure composite... .................. M................. ........... ........... ........... ........... ...........
0005F.............. Osteoarthritis composite.. .................. M................. ........... ........... ........... ........... ...........
00100.............. Anesth, salivary gland.... .................. N................. ........... ........... ........... ........... ...........
00102.............. Anesth, repair of cleft .................. N................. ........... ........... ........... ........... ...........
lip.
00103.............. Anesth, blepharoplasty.... .................. N................. ........... ........... ........... ........... ...........
00104.............. Anesth, electroshock...... .................. N................. ........... ........... ........... ........... ...........
00120.............. Anesth, ear surgery....... .................. N................. ........... ........... ........... ........... ...........
00124.............. Anesth, ear exam.......... .................. N................. ........... ........... ........... ........... ...........
00126.............. Anesth, tympanotomy....... .................. N................. ........... ........... ........... ........... ...........
0012F.............. Cap bacterial assess...... .................. M................. ........... ........... ........... ........... ...........
00140.............. Anesth, procedures on eye. .................. N................. ........... ........... ........... ........... ...........
00142.............. Anesth, lens surgery...... .................. N................. ........... ........... ........... ........... ...........
00144.............. Anesth, corneal transplant .................. N................. ........... ........... ........... ........... ...........
00145.............. Anesth, vitreoretinal surg .................. N................. ........... ........... ........... ........... ...........
00147.............. Anesth, iridectomy........ .................. N................. ........... ........... ........... ........... ...........
00148.............. Anesth, eye exam.......... .................. N................. ........... ........... ........... ........... ...........
0014F.............. Comp preop assess cat surg NI................ M................. ........... ........... ........... ........... ...........
0015F.............. Melan follow-up complete.. NI................ M................. ........... ........... ........... ........... ...........
00160.............. Anesth, nose/sinus surgery .................. N................. ........... ........... ........... ........... ...........
00162.............. Anesth, nose/sinus surgery .................. N................. ........... ........... ........... ........... ...........
00164.............. Anesth, biopsy of nose.... .................. N................. ........... ........... ........... ........... ...........
0016T.............. Thermotx choroid vasc .................. T................. 0235 4.1331 $263.25 $58.93 $52.65
lesion.
00170.............. Anesth, procedure on mouth .................. N................. ........... ........... ........... ........... ...........
00172.............. Anesth, cleft palate .................. N................. ........... ........... ........... ........... ...........
repair.
00174.............. Anesth, pharyngeal surgery .................. N................. ........... ........... ........... ........... ...........
00176.............. Anesth, pharyngeal surgery .................. C................. ........... ........... ........... ........... ...........
0017T.............. Photocoagulat macular .................. T................. 0235 4.1331 $263.25 $58.93 $52.65
drusen.
00190.............. Anesth, face/skull bone .................. N................. ........... ........... ........... ........... ...........
surg.
00192.............. Anesth, facial bone .................. C................. ........... ........... ........... ........... ...........
surgery.
0019T.............. Extracorp shock wv tx,ms .................. A................. ........... ........... ........... ........... ...........
nos.
00210.............. Anesth, open head surgery. .................. N................. ........... ........... ........... ........... ...........
00212.............. Anesth, skull drainage.... .................. N................. ........... ........... ........... ........... ...........
00214.............. Anesth, skull drainage.... .................. C................. ........... ........... ........... ........... ...........
00215.............. Anesth, skull repair/fract .................. C................. ........... ........... ........... ........... ...........
00216.............. Anesth, head vessel .................. N................. ........... ........... ........... ........... ...........
surgery.
00218.............. Anesth, special head .................. N................. ........... ........... ........... ........... ...........
surgery.
00220.............. Anesth, intrcrn nerve..... .................. N................. ........... ........... ........... ........... ...........
00222.............. Anesth, head nerve surgery .................. N................. ........... ........... ........... ........... ...........
0026T.............. Measure remnant .................. A................. ........... ........... ........... ........... ...........
lipoproteins.
0027T.............. Endoscopic epidural lysis. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
0028T.............. Dexa body composition .................. N................. ........... ........... ........... ........... ...........
study.
0029T.............. Magnetic tx for .................. A................. ........... ........... ........... ........... ...........
incontinence.
00300.............. Anesth, head/neck/ptrunk.. .................. N................. ........... ........... ........... ........... ...........
0030T.............. Antiprothrombin antibody.. .................. A................. ........... ........... ........... ........... ...........
0031T.............. Speculoscopy.............. .................. N................. ........... ........... ........... ........... ...........
00320.............. Anesth, neck organ, 1 & .................. N................. ........... ........... ........... ........... ...........
over.
00322.............. Anesth, biopsy of thyroid. .................. N................. ........... ........... ........... ........... ...........
00326.............. Anesth, larynx/trach, < 1 .................. N................. ........... ........... ........... ........... ...........
yr.
0032T.............. Speculoscopy w/direct .................. N................. ........... ........... ........... ........... ...........
sample.
00350.............. Anesth, neck vessel .................. N................. ........... ........... ........... ........... ...........
surgery.
00352.............. Anesth, neck vessel .................. N................. ........... ........... ........... ........... ...........
surgery.
00400.............. Anesth, skin, ext/per/ .................. N................. ........... ........... ........... ........... ...........
atrunk.
00402.............. Anesth, surgery of breast. .................. N................. ........... ........... ........... ........... ...........
00404.............. Anesth, surgery of breast. .................. N................. ........... ........... ........... ........... ...........
00406.............. Anesth, surgery of breast. .................. N................. ........... ........... ........... ........... ...........
00410.............. Anesth, correct heart .................. N................. ........... ........... ........... ........... ...........
rhythm.
0041T.............. Detect ur infect agnt w/ .................. A................. ........... ........... ........... ........... ...........
cpas.
0042T.............. Ct perfusion w/contrast, .................. N................. ........... ........... ........... ........... ...........
cbf.
0043T.............. Co expired gas analysis... .................. A................. ........... ........... ........... ........... ...........
00450.............. Anesth, surgery of .................. N................. ........... ........... ........... ........... ...........
shoulder.
00452.............. Anesth, surgery of .................. C................. ........... ........... ........... ........... ...........
shoulder.
00454.............. Anesth, collar bone biopsy .................. N................. ........... ........... ........... ........... ...........
[[Page 66994]]
0046T.............. Cath lavage, mammary .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
duct(s).
00470.............. Anesth, removal of rib.... .................. N................. ........... ........... ........... ........... ...........
00472.............. Anesth, chest wall repair. .................. N................. ........... ........... ........... ........... ...........
00474.............. Anesth, surgery of rib(s). .................. C................. ........... ........... ........... ........... ...........
0047T.............. Cath lavage, mammary .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
duct(s).
0048T.............. Implant ventricular device .................. C................. ........... ........... ........... ........... ...........
0049T.............. External circulation .................. C................. ........... ........... ........... ........... ...........
assist.
00500.............. Anesth, esophageal surgery .................. N................. ........... ........... ........... ........... ...........
0050T.............. Removal circulation assist .................. C................. ........... ........... ........... ........... ...........
0051T.............. Implant total heart system .................. C................. ........... ........... ........... ........... ...........
00520.............. Anesth, chest procedure... .................. N................. ........... ........... ........... ........... ...........
00522.............. Anesth, chest lining .................. N................. ........... ........... ........... ........... ...........
biopsy.
00524.............. Anesth, chest drainage.... .................. C................. ........... ........... ........... ........... ...........
00528.............. Anesth, chest partition .................. N................. ........... ........... ........... ........... ...........
view.
00529.............. Anesth, chest partition .................. N................. ........... ........... ........... ........... ...........
view.
0052T.............. Replace component heart .................. C................. ........... ........... ........... ........... ...........
syst.
00530.............. Anesth, pacemaker .................. N................. ........... ........... ........... ........... ...........
insertion.
00532.............. Anesth, vascular access... .................. N................. ........... ........... ........... ........... ...........
00534.............. Anesth, cardioverter/defib .................. N................. ........... ........... ........... ........... ...........
00537.............. Anesth, cardiac .................. N................. ........... ........... ........... ........... ...........
electrophys.
00539.............. Anesth, trach-bronch .................. N................. ........... ........... ........... ........... ...........
reconst.
0053T.............. Replace component heart .................. C................. ........... ........... ........... ........... ...........
syst.
00540.............. Anesth, chest surgery..... .................. C................. ........... ........... ........... ........... ...........
00541.............. Anesth, one lung .................. N................. ........... ........... ........... ........... ...........
ventilation.
00542.............. Anesth, release of lung... .................. C................. ........... ........... ........... ........... ...........
00546.............. Anesth, lung,chest wall .................. C................. ........... ........... ........... ........... ...........
surg.
00548.............. Anesth, trachea,bronchi .................. N................. ........... ........... ........... ........... ...........
surg.
0054T.............. Bone surgery using CH................ D................. ........... ........... ........... ........... ...........
computer.
00550.............. Anesth, sternal .................. N................. ........... ........... ........... ........... ...........
debridement.
0055T.............. Bone surgery using CH................ D................. ........... ........... ........... ........... ...........
computer.
00560.............. Anesth, heart surg w/o .................. C................. ........... ........... ........... ........... ...........
pump.
00561.............. Anesth, heart surg < age 1 .................. C................. ........... ........... ........... ........... ...........
00562.............. Anesth, heart surg w/pump. .................. C................. ........... ........... ........... ........... ...........
00563.............. Anesth, heart surg w/ .................. N................. ........... ........... ........... ........... ...........
arrest.
00566.............. Anesth, cabg w/o pump..... .................. N................. ........... ........... ........... ........... ...........
0056T.............. Bone surgery using CH................ D................. ........... ........... ........... ........... ...........
computer.
00580.............. Anesth, heart/lung .................. C................. ........... ........... ........... ........... ...........
transplnt.
0058T.............. Cryopreservation, ovary CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
tiss.
0059T.............. Cryopreservation, oocyte.. CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
00600.............. Anesth, spine, cord .................. N................. ........... ........... ........... ........... ...........
surgery.
00604.............. Anesth, sitting procedure. .................. C................. ........... ........... ........... ........... ...........
0060T.............. Electrical impedance scan. .................. B................. ........... ........... ........... ........... ...........
0061T.............. Destruction of tumor, .................. B................. ........... ........... ........... ........... ...........
breast.
00620.............. Anesth, spine, cord .................. N................. ........... ........... ........... ........... ...........
surgery.
00622.............. Anesth, removal of nerves. .................. C................. ........... ........... ........... ........... ...........
00625.............. Anes spine tranthor w/o .................. N................. ........... ........... ........... ........... ...........
vent.
00626.............. Anes, spine transthor w/ .................. N................. ........... ........... ........... ........... ...........
vent.
0062T.............. Rep intradisc annulus;1 .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lev.
00630.............. Anesth, spine, cord .................. N................. ........... ........... ........... ........... ...........
surgery.
00632.............. Anesth, removal of nerves. .................. C................. ........... ........... ........... ........... ...........
00634.............. Anesth for .................. N................. ........... ........... ........... ........... ...........
chemonucleolysis.
00635.............. Anesth, lumbar puncture... .................. N................. ........... ........... ........... ........... ...........
0063T.............. Rep intradisc .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
annulus;>1lev.
00640.............. Anesth, spine manipulation .................. N................. ........... ........... ........... ........... ...........
0064T.............. Spectroscop eval expired .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
gas.
0065T.............. Ocular photoscreen bilat.. CH................ D................. ........... ........... ........... ........... ...........
0066T.............. Ct colonography;screen.... .................. E................. ........... ........... ........... ........... ...........
00670.............. Anesth, spine, cord .................. C................. ........... ........... ........... ........... ...........
surgery.
0067T.............. Ct colonography;dx........ CH................ S................. 0332 3.0109 $191.78 $75.24 $38.36
0068T.............. Interp/rept heart sound... .................. B................. ........... ........... ........... ........... ...........
0069T.............. Analysis only heart sound. .................. N................. ........... ........... ........... ........... ...........
00700.............. Anesth, abdominal wall .................. N................. ........... ........... ........... ........... ...........
surg.
00702.............. Anesth, for liver biopsy.. .................. N................. ........... ........... ........... ........... ...........
0070T.............. Interp only heart sound... .................. B................. ........... ........... ........... ........... ...........
0071T.............. U/s leiomyomata ablate CH................ S................. 0067 61.6965 $3,929.70 ........... $785.94
<200.
0072T.............. U/s leiomyomata ablate CH................ S................. 0067 61.6965 $3,929.70 ........... $785.94
>200.
00730.............. Anesth, abdominal wall .................. N................. ........... ........... ........... ........... ...........
surg.
0073T.............. Delivery, comp imrt....... .................. S................. 0412 5.4582 $347.65 ........... $69.53
00740.............. Anesth, upper gi visualize .................. N................. ........... ........... ........... ........... ...........
0074T.............. Online physician e/m...... CH................ D................. ........... ........... ........... ........... ...........
00750.............. Anesth, repair of hernia.. .................. N................. ........... ........... ........... ........... ...........
00752.............. Anesth, repair of hernia.. .................. N................. ........... ........... ........... ........... ...........
00754.............. Anesth, repair of hernia.. .................. N................. ........... ........... ........... ........... ...........
00756.............. Anesth, repair of hernia.. .................. N................. ........... ........... ........... ........... ...........
0075T.............. Perq stent/chest vert art. .................. C................. ........... ........... ........... ........... ...........
0076T.............. S&i stent/chest vert art.. .................. C................. ........... ........... ........... ........... ...........
00770.............. Anesth, blood vessel .................. N................. ........... ........... ........... ........... ...........
repair.
0077T.............. Cereb therm perfusion .................. C................. ........... ........... ........... ........... ...........
probe.
0078T.............. Endovasc aort repr w/ .................. C................. ........... ........... ........... ........... ...........
device.
00790.............. Anesth, surg upper abdomen .................. N................. ........... ........... ........... ........... ...........
[[Page 66995]]
00792.............. Anesth, hemorr/excise .................. C................. ........... ........... ........... ........... ...........
liver.
00794.............. Anesth, pancreas removal.. .................. C................. ........... ........... ........... ........... ...........
00796.............. Anesth, for liver .................. C................. ........... ........... ........... ........... ...........
transplant.
00797.............. Anesth, surgery for .................. N................. ........... ........... ........... ........... ...........
obesity.
0079T.............. Endovasc visc extnsn repr. .................. C................. ........... ........... ........... ........... ...........
00800.............. Anesth, abdominal wall .................. N................. ........... ........... ........... ........... ...........
surg.
00802.............. Anesth, fat layer removal. .................. C................. ........... ........... ........... ........... ...........
0080T.............. Endovasc aort repr rad s&i .................. C................. ........... ........... ........... ........... ...........
00810.............. Anesth, low intestine .................. N................. ........... ........... ........... ........... ...........
scope.
0081T.............. Endovasc visc extnsn s&i.. .................. C................. ........... ........... ........... ........... ...........
00820.............. Anesth, abdominal wall .................. N................. ........... ........... ........... ........... ...........
surg.
00830.............. Anesth, repair of hernia.. .................. N................. ........... ........... ........... ........... ...........
00832.............. Anesth, repair of hernia.. .................. N................. ........... ........... ........... ........... ...........
00834.............. Anesth, hernia repair< 1 .................. N................. ........... ........... ........... ........... ...........
yr.
00836.............. Anesth hernia repair .................. N................. ........... ........... ........... ........... ...........
preemie.
00840.............. Anesth, surg lower abdomen .................. N................. ........... ........... ........... ........... ...........
00842.............. Anesth, amniocentesis..... .................. N................. ........... ........... ........... ........... ...........
00844.............. Anesth, pelvis surgery.... .................. C................. ........... ........... ........... ........... ...........
00846.............. Anesth, hysterectomy...... .................. C................. ........... ........... ........... ........... ...........
00848.............. Anesth, pelvic organ surg. .................. C................. ........... ........... ........... ........... ...........
0084T.............. Temp prostate urethral .................. T................. 0164 2.0077 $127.88 ........... $25.58
stent.
00851.............. Anesth, tubal ligation.... .................. N................. ........... ........... ........... ........... ...........
0085T.............. Breath test heart reject.. .................. X................. 0340 0.6310 $40.19 ........... $8.04
00860.............. Anesth, surgery of abdomen .................. N................. ........... ........... ........... ........... ...........
00862.............. Anesth, kidney/ureter surg .................. N................. ........... ........... ........... ........... ...........
00864.............. Anesth, removal of bladder .................. C................. ........... ........... ........... ........... ...........
00865.............. Anesth, removal of .................. C................. ........... ........... ........... ........... ...........
prostate.
00866.............. Anesth, removal of adrenal .................. C................. ........... ........... ........... ........... ...........
00868.............. Anesth, kidney transplant. .................. C................. ........... ........... ........... ........... ...........
0086T.............. L ventricle fill pressure. .................. N................. ........... ........... ........... ........... ...........
00870.............. Anesth, bladder stone surg .................. N................. ........... ........... ........... ........... ...........
00872.............. Anesth kidney stone .................. N................. ........... ........... ........... ........... ...........
destruct.
00873.............. Anesth kidney stone .................. N................. ........... ........... ........... ........... ...........
destruct.
0087T.............. Sperm eval hyaluronan..... CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
00880.............. Anesth, abdomen vessel .................. N................. ........... ........... ........... ........... ...........
surg.
00882.............. Anesth, major vein .................. C................. ........... ........... ........... ........... ...........
ligation.
0088T.............. Rf tongue base vol reduxn. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
0089T.............. Actigraphy testing, 3-day. .................. S................. 0218 1.1550 $73.57 ........... $14.71
00902.............. Anesth, anorectal surgery. .................. N................. ........... ........... ........... ........... ...........
00904.............. Anesth, perineal surgery.. .................. C................. ........... ........... ........... ........... ...........
00906.............. Anesth, removal of vulva.. .................. N................. ........... ........... ........... ........... ...........
00908.............. Anesth, removal of .................. C................. ........... ........... ........... ........... ...........
prostate.
0090T.............. Cervical artific disc..... .................. C................. ........... ........... ........... ........... ...........
00910.............. Anesth, bladder surgery... .................. N................. ........... ........... ........... ........... ...........
00912.............. Anesth, bladder tumor surg .................. N................. ........... ........... ........... ........... ...........
00914.............. Anesth, removal of .................. N................. ........... ........... ........... ........... ...........
prostate.
00916.............. Anesth, bleeding control.. .................. N................. ........... ........... ........... ........... ...........
00918.............. Anesth, stone removal..... .................. N................. ........... ........... ........... ........... ...........
00920.............. Anesth, genitalia surgery. .................. N................. ........... ........... ........... ........... ...........
00921.............. Anesth, vasectomy......... .................. N................. ........... ........... ........... ........... ...........
00922.............. Anesth, sperm duct surgery .................. N................. ........... ........... ........... ........... ...........
00924.............. Anesth, testis exploration .................. N................. ........... ........... ........... ........... ...........
00926.............. Anesth, removal of testis. .................. N................. ........... ........... ........... ........... ...........
00928.............. Anesth, removal of testis. .................. N................. ........... ........... ........... ........... ...........
0092T.............. Artific disc addl......... .................. C................. ........... ........... ........... ........... ...........
00930.............. Anesth, testis suspension. .................. N................. ........... ........... ........... ........... ...........
00932.............. Anesth, amputation of .................. C................. ........... ........... ........... ........... ...........
penis.
00934.............. Anesth, penis, nodes .................. C................. ........... ........... ........... ........... ...........
removal.
00936.............. Anesth, penis, nodes .................. C................. ........... ........... ........... ........... ...........
removal.
00938.............. Anesth, insert penis .................. N................. ........... ........... ........... ........... ...........
device.
0093T.............. Cervical artific .................. C................. ........... ........... ........... ........... ...........
diskectomy.
00940.............. Anesth, vaginal procedures .................. N................. ........... ........... ........... ........... ...........
00942.............. Anesth, surg on vag/ .................. N................. ........... ........... ........... ........... ...........
urethral.
00944.............. Anesth, vaginal .................. C................. ........... ........... ........... ........... ...........
hysterectomy.
00948.............. Anesth, repair of cervix.. .................. N................. ........... ........... ........... ........... ...........
00950.............. Anesth, vaginal endoscopy. .................. N................. ........... ........... ........... ........... ...........
00952.............. Anesth, hysteroscope/graph .................. N................. ........... ........... ........... ........... ...........
0095T.............. Artific diskectomy addl... .................. C................. ........... ........... ........... ........... ...........
0096T.............. Rev cervical artific disc. .................. C................. ........... ........... ........... ........... ...........
0098T.............. Rev artific disc addl..... .................. C................. ........... ........... ........... ........... ...........
0099T.............. Implant corneal ring...... .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
0100T.............. Prosth retina receive&gen. .................. T................. 0672 37.2078 $2,369.91 ........... $473.98
0101T.............. Extracorp shockwv tx,hi .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
enrg.
0102T.............. Extracorp shockwv .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
tx,anesth.
0103T.............. Holotranscobalamin........ .................. A................. ........... ........... ........... ........... ...........
0104T.............. At rest cardio gas .................. A................. ........... ........... ........... ........... ...........
rebreathe.
0105T.............. Exerc cardio gas rebreathe .................. A................. ........... ........... ........... ........... ...........
0106T.............. Touch quant sensory test.. .................. X................. 0341 0.0844 $5.38 $2.14 $1.08
0107T.............. Vibrate quant sensory test .................. X................. 0341 0.0844 $5.38 $2.14 $1.08
0108T.............. Cool quant sensory test... .................. X................. 0341 0.0844 $5.38 $2.14 $1.08
[[Page 66996]]
0109T.............. Heat quant sensory test... .................. X................. 0341 0.0844 $5.38 $2.14 $1.08
0110T.............. Nos quant sensory test.... .................. X................. 0341 0.0844 $5.38 $2.14 $1.08
01112.............. Anesth, bone aspirate/bx.. .................. N................. ........... ........... ........... ........... ...........
0111T.............. Rbc membranes fatty acids. .................. A................. ........... ........... ........... ........... ...........
01120.............. Anesth, pelvis surgery.... .................. N................. ........... ........... ........... ........... ...........
01130.............. Anesth, body cast .................. N................. ........... ........... ........... ........... ...........
procedure.
01140.............. Anesth, amputation at .................. C................. ........... ........... ........... ........... ...........
pelvis.
01150.............. Anesth, pelvic tumor .................. C................. ........... ........... ........... ........... ...........
surgery.
0115T.............. Med tx mngmt 15 min....... CH................ D................. ........... ........... ........... ........... ...........
01160.............. Anesth, pelvis procedure.. .................. N................. ........... ........... ........... ........... ...........
0116T.............. Med tx mngmt subsqt....... CH................ D................. ........... ........... ........... ........... ...........
01170.............. Anesth, pelvis surgery.... .................. N................. ........... ........... ........... ........... ...........
01173.............. Anesth, fx repair, pelvis. .................. N................. ........... ........... ........... ........... ...........
0117T.............. Med tx mngmt addl 15 min.. CH................ D................. ........... ........... ........... ........... ...........
01180.............. Anesth, pelvis nerve .................. N................. ........... ........... ........... ........... ...........
removal.
01190.............. Anesth, pelvis nerve .................. N................. ........... ........... ........... ........... ...........
removal.
01200.............. Anesth, hip joint .................. N................. ........... ........... ........... ........... ...........
procedure.
01202.............. Anesth, arthroscopy of hip .................. N................. ........... ........... ........... ........... ...........
01210.............. Anesth, hip joint surgery. .................. N................. ........... ........... ........... ........... ...........
01212.............. Anesth, hip .................. C................. ........... ........... ........... ........... ...........
disarticulation.
01214.............. Anesth, hip arthroplasty.. .................. C................. ........... ........... ........... ........... ...........
01215.............. Anesth, revise hip repair. .................. N................. ........... ........... ........... ........... ...........
01220.............. Anesth, procedure on femur .................. N................. ........... ........... ........... ........... ...........
01230.............. Anesth, surgery of femur.. .................. N................. ........... ........... ........... ........... ...........
01232.............. Anesth, amputation of .................. C................. ........... ........... ........... ........... ...........
femur.
01234.............. Anesth, radical femur surg .................. C................. ........... ........... ........... ........... ...........
0123T.............. Scleral fistulization..... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
0124T.............. Conjunctival drug .................. T................. 0232 5.1169 $325.92 $81.65 $65.18
placement.
01250.............. Anesth, upper leg surgery. .................. N................. ........... ........... ........... ........... ...........
01260.............. Anesth, upper leg veins .................. N................. ........... ........... ........... ........... ...........
surg.
0126T.............. Chd risk imt study........ CH................ Q................. 0340 0.6310 $40.19 ........... $8.04
01270.............. Anesth, thigh arteries .................. N................. ........... ........... ........... ........... ...........
surg.
01272.............. Anesth, femoral artery .................. C................. ........... ........... ........... ........... ...........
surg.
01274.............. Anesth, femoral .................. C................. ........... ........... ........... ........... ...........
embolectomy.
0130T.............. Chron care drug .................. B................. ........... ........... ........... ........... ...........
investigatn.
01320.............. Anesth, knee area surgery. .................. N................. ........... ........... ........... ........... ...........
01340.............. Anesth, knee area .................. N................. ........... ........... ........... ........... ...........
procedure.
0135T.............. Perq cryoablate renal CH................ D................. ........... ........... ........... ........... ...........
tumor.
01360.............. Anesth, knee area surgery. .................. N................. ........... ........... ........... ........... ...........
0137T.............. Prostate saturation .................. T................. 0184 11.0338 $702.79 ........... $140.56
sampling.
01380.............. Anesth, knee joint .................. N................. ........... ........... ........... ........... ...........
procedure.
01382.............. Anesth, dx knee .................. N................. ........... ........... ........... ........... ...........
arthroscopy.
01390.............. Anesth, knee area .................. N................. ........... ........... ........... ........... ...........
procedure.
01392.............. Anesth, knee area surgery. .................. N................. ........... ........... ........... ........... ...........
01400.............. Anesth, knee joint surgery .................. N................. ........... ........... ........... ........... ...........
01402.............. Anesth, knee arthroplasty. .................. C................. ........... ........... ........... ........... ...........
01404.............. Anesth, amputation at knee .................. C................. ........... ........... ........... ........... ...........
0140T.............. Exhaled breath condensate .................. A................. ........... ........... ........... ........... ...........
ph.
0141T.............. Perq islet transplant..... .................. E................. ........... ........... ........... ........... ...........
01420.............. Anesth, knee joint casting .................. N................. ........... ........... ........... ........... ...........
0142T.............. Open islet transplant..... .................. E................. ........... ........... ........... ........... ...........
01430.............. Anesth, knee veins surgery .................. N................. ........... ........... ........... ........... ...........
01432.............. Anesth, knee vessel surg.. .................. N................. ........... ........... ........... ........... ...........
0143T.............. Laparoscopic islet .................. E................. ........... ........... ........... ........... ...........
transplnt.
01440.............. Anesth, knee arteries surg .................. N................. ........... ........... ........... ........... ...........
01442.............. Anesth, knee artery surg.. .................. C................. ........... ........... ........... ........... ...........
01444.............. Anesth, knee artery repair .................. C................. ........... ........... ........... ........... ...........
0144T.............. CT heart wo dye; qual calc CH................ S................. 0282 1.5839 $100.88 $37.81 $20.18
0145T.............. CT heart w/wo dye funct... CH................ S................. 0383 4.7005 $299.39 $117.06 $59.88
01462.............. Anesth, lower leg .................. N................. ........... ........... ........... ........... ...........
procedure.
01464.............. Anesth, ankle/ft .................. N................. ........... ........... ........... ........... ...........
arthroscopy.
0146T.............. CCTA w/wo dye............. CH................ S................. 0383 4.7005 $299.39 $117.06 $59.88
01470.............. Anesth, lower leg surgery. .................. N................. ........... ........... ........... ........... ...........
01472.............. Anesth, achilles tendon .................. N................. ........... ........... ........... ........... ...........
surg.
01474.............. Anesth, lower leg surgery. .................. N................. ........... ........... ........... ........... ...........
0147T.............. CCTA w/wo, quan calcium... CH................ S................. 0383 4.7005 $299.39 $117.06 $59.88
01480.............. Anesth, lower leg bone .................. N................. ........... ........... ........... ........... ...........
surg.
01482.............. Anesth, radical leg .................. N................. ........... ........... ........... ........... ...........
surgery.
01484.............. Anesth, lower leg revision .................. N................. ........... ........... ........... ........... ...........
01486.............. Anesth, ankle replacement. .................. C................. ........... ........... ........... ........... ...........
0148T.............. CCTA w/wo, strxr.......... CH................ S................. 0383 4.7005 $299.39 $117.06 $59.88
01490.............. Anesth, lower leg casting. .................. N................. ........... ........... ........... ........... ...........
0149T.............. CCTA w/wo, strxr quan calc CH................ S................. 0383 4.7005 $299.39 $117.06 $59.88
01500.............. Anesth, leg arteries surg. .................. N................. ........... ........... ........... ........... ...........
01502.............. Anesth, lwr leg .................. C................. ........... ........... ........... ........... ...........
embolectomy.
0150T.............. CCTA w/wo, disease strxr.. CH................ S................. 0383 4.7005 $299.39 $117.06 $59.88
0151T.............. CT heart funct add-on..... .................. S................. 0282 1.5839 $100.88 $37.81 $20.18
01520.............. Anesth, lower leg vein .................. N................. ........... ........... ........... ........... ...........
surg.
01522.............. Anesth, lower leg vein .................. N................. ........... ........... ........... ........... ...........
surg.
0153T.............. Tcath sensor aneurysm sac. CH................ D................. ........... ........... ........... ........... ...........
[[Page 66997]]
0154T.............. Study sensor aneurysm sac. CH................ D................. ........... ........... ........... ........... ...........
0155T.............. Lap impl gast curve .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
electrd.
0156T.............. Lap remv gast curve .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
electrd.
0157T.............. Open impl gast curve .................. C................. ........... ........... ........... ........... ...........
electrd.
0158T.............. Open remv gast curve .................. C................. ........... ........... ........... ........... ...........
electrd.
0159T.............. Cad breast mri............ .................. N................. ........... ........... ........... ........... ...........
0160T.............. Tcranial magn stim tx plan .................. S................. 0216 2.6846 $170.99 ........... $34.20
01610.............. Anesth, surgery of .................. N................. ........... ........... ........... ........... ...........
shoulder.
0161T.............. Tcranial magn stim tx .................. S................. 0216 2.6846 $170.99 ........... $34.20
deliv.
01620.............. Anesth, shoulder procedure .................. N................. ........... ........... ........... ........... ...........
01622.............. Anes dx shoulder .................. N................. ........... ........... ........... ........... ...........
arthroscopy.
0162T.............. Anal program gast .................. S................. 0692 1.8376 $117.04 $29.72 $23.41
neurostim.
01630.............. Anesth, surgery of .................. N................. ........... ........... ........... ........... ...........
shoulder.
01632.............. Anesth, surgery of .................. C................. ........... ........... ........... ........... ...........
shoulder.
01634.............. Anesth, shoulder joint .................. C................. ........... ........... ........... ........... ...........
amput.
01636.............. Anesth, forequarter amput. .................. C................. ........... ........... ........... ........... ...........
01638.............. Anesth, shoulder .................. C................. ........... ........... ........... ........... ...........
replacement.
0163T.............. Lumb artif diskectomy addl .................. C................. ........... ........... ........... ........... ...........
0164T.............. Remove lumb artif disc .................. C................. ........... ........... ........... ........... ...........
addl.
01650.............. Anesth, shoulder artery .................. N................. ........... ........... ........... ........... ...........
surg.
01652.............. Anesth, shoulder vessel .................. C................. ........... ........... ........... ........... ...........
surg.
01654.............. Anesth, shoulder vessel .................. C................. ........... ........... ........... ........... ...........
surg.
01656.............. Anesth, arm-leg vessel .................. C................. ........... ........... ........... ........... ...........
surg.
0165T.............. Revise lumb artif disc .................. C................. ........... ........... ........... ........... ...........
addl.
0166T.............. Tcath vsd close w/o bypass .................. C................. ........... ........... ........... ........... ...........
01670.............. Anesth, shoulder vein surg .................. N................. ........... ........... ........... ........... ...........
0167T.............. Tcath vsd close w bypass.. .................. C................. ........... ........... ........... ........... ...........
01680.............. Anesth, shoulder casting.. .................. N................. ........... ........... ........... ........... ...........
01682.............. Anesth, airplane cast..... .................. N................. ........... ........... ........... ........... ...........
0168T.............. Rhinophototx light app .................. T................. 0251 2.5002 $159.25 ........... $31.85
bilat.
0169T.............. Place stereo cath brain... .................. C................. ........... ........... ........... ........... ...........
0170T.............. Anorectal fistula plug rpr .................. T................. 0150 30.1606 $1,921.05 $437.12 $384.21
01710.............. Anesth, elbow area surgery .................. N................. ........... ........... ........... ........... ...........
01712.............. Anesth, uppr arm tendon .................. N................. ........... ........... ........... ........... ...........
surg.
01714.............. Anesth, uppr arm tendon .................. N................. ........... ........... ........... ........... ...........
surg.
01716.............. Anesth, biceps tendon .................. N................. ........... ........... ........... ........... ...........
repair.
0171T.............. Lumbar spine proces .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
distract.
0172T.............. Lumbar spine process addl. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
01730.............. Anesth, uppr arm procedure .................. N................. ........... ........... ........... ........... ...........
01732.............. Anesth, dx elbow .................. N................. ........... ........... ........... ........... ...........
arthroscopy.
0173T.............. Iop monit io pressure..... .................. N................. ........... ........... ........... ........... ...........
01740.............. Anesth, upper arm surgery. .................. N................. ........... ........... ........... ........... ...........
01742.............. Anesth, humerus surgery... .................. N................. ........... ........... ........... ........... ...........
01744.............. Anesth, humerus repair.... .................. N................. ........... ........... ........... ........... ...........
0174T.............. Cad cxr with interp....... .................. N................. ........... ........... ........... ........... ...........
01756.............. Anesth, radical humerus .................. C................. ........... ........... ........... ........... ...........
surg.
01758.............. Anesth, humeral lesion .................. N................. ........... ........... ........... ........... ...........
surg.
0175T.............. Cad cxr remote............ .................. N................. ........... ........... ........... ........... ...........
01760.............. Anesth, elbow replacement. .................. N................. ........... ........... ........... ........... ...........
0176T.............. Aqu canal dilat w/o retent .................. T................. 0673 39.7101 $2,529.30 $649.56 $505.86
01770.............. Anesth, uppr arm artery .................. N................. ........... ........... ........... ........... ...........
surg.
01772.............. Anesth, uppr arm .................. N................. ........... ........... ........... ........... ...........
embolectomy.
0177T.............. Aqu canal dilat w retent.. .................. T................. 0673 39.7101 $2,529.30 $649.56 $505.86
01780.............. Anesth, upper arm vein .................. N................. ........... ........... ........... ........... ...........
surg.
01782.............. Anesth, uppr arm vein .................. N................. ........... ........... ........... ........... ...........
repair.
0178T.............. 64 lead ecg w i&r......... NF................ B................. ........... ........... ........... ........... ...........
0179T.............. 64 lead ecg w tracing..... NF................ X................. 0100 2.5547 $162.72 $41.44 $32.54
0180T.............. 64 lead ecg w i&r only.... NF................ B................. ........... ........... ........... ........... ...........
01810.............. Anesth, lower arm surgery. .................. N................. ........... ........... ........... ........... ...........
0181T.............. Corneal hysteresis........ NF................ S................. 0230 0.5903 $37.60 ........... $7.52
01820.............. Anesth, lower arm .................. N................. ........... ........... ........... ........... ...........
procedure.
01829.............. Anesth, dx wrist .................. N................. ........... ........... ........... ........... ...........
arthroscopy.
0182T.............. Hdr elect brachytherapy... NF................ S................. 1519 ........... $1,750.00 ........... $350.00
01830.............. Anesth, lower arm surgery. .................. N................. ........... ........... ........... ........... ...........
01832.............. Anesth, wrist replacement. .................. N................. ........... ........... ........... ........... ...........
0183T.............. Wound ultrasound.......... NI................ T................. 0015 1.4595 $92.96 ........... $18.59
01840.............. Anesth, lwr arm artery .................. N................. ........... ........... ........... ........... ...........
surg.
01842.............. Anesth, lwr arm .................. N................. ........... ........... ........... ........... ...........
embolectomy.
01844.............. Anesth, vascular shunt .................. N................. ........... ........... ........... ........... ...........
surg.
0184T.............. Exc rectal tumor NI................ C................. ........... ........... ........... ........... ...........
endoscopic.
01850.............. Anesth, lower arm vein .................. N................. ........... ........... ........... ........... ...........
surg.
01852.............. Anesth, lwr arm vein .................. N................. ........... ........... ........... ........... ...........
repair.
0185T.............. Comptr probability NI................ N................. ........... ........... ........... ........... ...........
analysis.
01860.............. Anesth, lower arm casting. .................. N................. ........... ........... ........... ........... ...........
0186T.............. Suprachoroidal drug NI................ T................. 0236 18.2350 $1,161.46 ........... $232.29
delivery.
0187T.............. Ophthalmic dx image NI................ S................. 0230 0.5903 $37.60 ........... $7.52
anterior.
01905.............. Anes, spine inject, x-ray/ CH................ D................. ........... ........... ........... ........... ...........
re.
01916.............. Anesth, dx arteriography.. .................. N................. ........... ........... ........... ........... ...........
01920.............. Anesth, catheterize heart. .................. N................. ........... ........... ........... ........... ...........
01922.............. Anesth, cat or MRI scan... .................. N................. ........... ........... ........... ........... ...........
[[Page 66998]]
01924.............. Anes, ther interven rad, .................. N................. ........... ........... ........... ........... ...........
art.
01925.............. Anes, ther interven rad, .................. N................. ........... ........... ........... ........... ...........
car.
01926.............. Anes, tx interv rad hrt/ .................. N................. ........... ........... ........... ........... ...........
cran.
01930.............. Anes, ther interven rad, .................. N................. ........... ........... ........... ........... ...........
vei.
01931.............. Anes, ther interven rad, .................. N................. ........... ........... ........... ........... ...........
tip.
01932.............. Anes, tx interv rad, th .................. N................. ........... ........... ........... ........... ...........
vein.
01933.............. Anes, tx interv rad, cran .................. N................. ........... ........... ........... ........... ...........
v.
01935.............. Anesth, perc img dx sp NI................ N................. ........... ........... ........... ........... ...........
proc.
01936.............. Anesth, perc img tx sp NI................ N................. ........... ........... ........... ........... ...........
proc.
01951.............. Anesth, burn, less 4 .................. N................. ........... ........... ........... ........... ...........
percent.
01952.............. Anesth, burn, 4-9 percent. .................. N................. ........... ........... ........... ........... ...........
01953.............. Anesth, burn, each 9 .................. N................. ........... ........... ........... ........... ...........
percent.
01958.............. Anesth, antepartum manipul .................. N................. ........... ........... ........... ........... ...........
01960.............. Anesth, vaginal delivery.. .................. N................. ........... ........... ........... ........... ...........
01961.............. Anesth, cs delivery....... .................. N................. ........... ........... ........... ........... ...........
01962.............. Anesth, emer hysterectomy. .................. N................. ........... ........... ........... ........... ...........
01963.............. Anesth, cs hysterectomy... .................. N................. ........... ........... ........... ........... ...........
01965.............. Anesth, inc/missed ab proc .................. N................. ........... ........... ........... ........... ...........
01966.............. Anesth, induced ab .................. N................. ........... ........... ........... ........... ...........
procedure.
01967.............. Anesth/analg, vag delivery .................. N................. ........... ........... ........... ........... ...........
01968.............. Anes/analg cs deliver add- .................. N................. ........... ........... ........... ........... ...........
on.
01969.............. Anesth/analg cs hyst add- .................. N................. ........... ........... ........... ........... ...........
on.
01990.............. Support for organ donor... .................. C................. ........... ........... ........... ........... ...........
01991.............. Anesth, nerve block/inj... .................. N................. ........... ........... ........... ........... ...........
01992.............. Anesth, n block/inj, prone .................. N................. ........... ........... ........... ........... ...........
01996.............. Hosp manage cont drug .................. N................. ........... ........... ........... ........... ...........
admin.
01999.............. Unlisted anesth procedure. .................. N................. ........... ........... ........... ........... ...........
0500F.............. Initial prenatal care .................. M................. ........... ........... ........... ........... ...........
visit.
0501F.............. Prenatal flow sheet....... .................. M................. ........... ........... ........... ........... ...........
0502F.............. Subsequent prenatal care.. .................. M................. ........... ........... ........... ........... ...........
0503F.............. Postpartum care visit..... .................. M................. ........... ........... ........... ........... ...........
0505F.............. Hemodialysis plan doc'd... .................. M................. ........... ........... ........... ........... ...........
0507F.............. Periton dialysis plan .................. M................. ........... ........... ........... ........... ...........
doc'd.
0509F.............. Urine incon plan doc'd.... .................. M................. ........... ........... ........... ........... ...........
0513F.............. Elev BP plan of care doc'd NI................ M................. ........... ........... ........... ........... ...........
0514F.............. Care plan Hgb doc'd ESA pt NI................ M................. ........... ........... ........... ........... ...........
0516F.............. Anemia plan of care doc'd. NI................ M................. ........... ........... ........... ........... ...........
0517F.............. Glaucoma plan of care NI................ M................. ........... ........... ........... ........... ...........
doc'd.
0518F.............. Fall plan of care doc'd... NI................ M................. ........... ........... ........... ........... ...........
0519F.............. Plan'd chemo doc'd b/4 NI................ M................. ........... ........... ........... ........... ...........
txmnt.
0520F.............. Tissue dose done w/in 5 NI................ M................. ........... ........... ........... ........... ...........
days.
0521F.............. Plan of care 4 pain doc'd. NI................ M................. ........... ........... ........... ........... ...........
1000F.............. Tobacco use assessed...... .................. M................. ........... ........... ........... ........... ...........
10021.............. Fna w/o image............. .................. T................. 0002 1.1097 $70.68 ........... $14.14
10022.............. Fna w/image............... CH................ T................. 0004 4.3270 $275.60 ........... $55.12
1002F.............. Assess anginal symptom/ .................. M................. ........... ........... ........... ........... ...........
level.
1003F.............. Level of activity assess.. .................. M................. ........... ........... ........... ........... ...........
10040.............. Acne surgery.............. CH................ T................. 0013 0.7930 $50.51 ........... $10.10
1004F.............. Clin symp vol ovrld assess .................. M................. ........... ........... ........... ........... ...........
1005F.............. Asthma symptoms evaluate.. .................. M................. ........... ........... ........... ........... ...........
10060.............. Drainage of skin abscess.. .................. T................. 0006 1.4066 $89.59 ........... $17.92
10061.............. Drainage of skin abscess.. .................. T................. 0006 1.4066 $89.59 ........... $17.92
1006F.............. Osteoarthritis assess..... .................. M................. ........... ........... ........... ........... ...........
1007F.............. Anti-inflm/anlgsc otc .................. M................. ........... ........... ........... ........... ...........
assess.
10080.............. Drainage of pilonidal cyst .................. T................. 0006 1.4066 $89.59 ........... $17.92
10081.............. Drainage of pilonidal cyst .................. T................. 0007 11.5594 $736.26 ........... $147.25
1008F.............. Gi/renal risk assess...... .................. M................. ........... ........... ........... ........... ...........
10120.............. Remove foreign body....... .................. T................. 0006 1.4066 $89.59 ........... $17.92
10121.............. Remove foreign body....... .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
10140.............. Drainage of hematoma/fluid .................. T................. 0007 11.5594 $736.26 ........... $147.25
1015F.............. Copd symptoms assess...... .................. M................. ........... ........... ........... ........... ...........
10160.............. Puncture drainage of CH................ T................. 0006 1.4066 $89.59 ........... $17.92
lesion.
10180.............. Complex drainage, wound... .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
1018F.............. Assess dyspnea not present .................. M................. ........... ........... ........... ........... ...........
1019F.............. Assess dyspnea present.... .................. M................. ........... ........... ........... ........... ...........
1022F.............. Pneumo imm status assess.. .................. M................. ........... ........... ........... ........... ...........
1026F.............. Co-morbid condition assess .................. M................. ........... ........... ........... ........... ...........
1030F.............. Influenza imm status .................. M................. ........... ........... ........... ........... ...........
assess.
1034F.............. Current tobacco smoker.... .................. M................. ........... ........... ........... ........... ...........
1035F.............. Smokeless tobacco user.... .................. M................. ........... ........... ........... ........... ...........
1036F.............. Tobacco non-user.......... .................. M................. ........... ........... ........... ........... ...........
1038F.............. Persistent asthma......... .................. M................. ........... ........... ........... ........... ...........
1039F.............. Intermittent asthma....... .................. M................. ........... ........... ........... ........... ...........
1040F.............. DSM-IV info MDD doc'd..... .................. M................. ........... ........... ........... ........... ...........
1050F.............. History of mole changes... .................. M................. ........... ........... ........... ........... ...........
1055F.............. Visual funct status assess .................. M................. ........... ........... ........... ........... ...........
1060F.............. Doc perm/cont/parox atr .................. M................. ........... ........... ........... ........... ...........
fib.
1061F.............. Doc lack perm+cont+parox .................. M................. ........... ........... ........... ........... ...........
fib.
1065F.............. Ischm stroke symp lt3 hrsb/ .................. M................. ........... ........... ........... ........... ...........
4.
1066F.............. Ischm stroke symp ge3 hrsb/ .................. M................. ........... ........... ........... ........... ...........
4.
[[Page 66999]]
1070F.............. Alarm symp assessed-absent .................. M................. ........... ........... ........... ........... ...........
1071F.............. Alarm symp assessed-1+ .................. M................. ........... ........... ........... ........... ...........
prsnt.
1080F.............. Decis mkr/advncd plan CH................ D................. ........... ........... ........... ........... ...........
doc'd.
1090F.............. Pres/absn urine incon .................. M................. ........... ........... ........... ........... ...........
assess.
1091F.............. Urine incon characterized. .................. M................. ........... ........... ........... ........... ...........
11000.............. Debride infected skin..... .................. T................. 0013 0.7930 $50.51 ........... $10.10
11001.............. Debride infected skin add- CH................ T................. 0013 0.7930 $50.51 ........... $10.10
on.
11004.............. Debride genitalia & .................. C................. ........... ........... ........... ........... ...........
perineum.
11005.............. Debride abdom wall........ .................. C................. ........... ........... ........... ........... ...........
11006.............. Debride genit/per/abdom .................. C................. ........... ........... ........... ........... ...........
wall.
11008.............. Remove mesh from abd wall. .................. C................. ........... ........... ........... ........... ...........
1100F.............. Ptfalls assess-doc'd ge2+/ .................. M................. ........... ........... ........... ........... ...........
yr.
11010.............. Debride skin, fx.......... .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
11011.............. Debride skin/muscle, fx... .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
11012.............. Debride skin/muscle/bone, .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
fx.
1101F.............. Pt falls assess-doc'd le1/ .................. M................. ........... ........... ........... ........... ...........
yr.
11040.............. Debride skin, partial..... .................. T................. 0015 1.4595 $92.96 ........... $18.59
11041.............. Debride skin, full........ .................. T................. 0015 1.4595 $92.96 ........... $18.59
11042.............. Debride skin/tissue....... .................. T................. 0016 2.6604 $169.45 ........... $33.89
11043.............. Debride tissue/muscle..... .................. T................. 0016 2.6604 $169.45 ........... $33.89
11044.............. Debride tissue/muscle/bone .................. T................. 0682 6.8816 $438.32 $158.65 $87.66
11055.............. Trim skin lesion.......... CH................ T................. 0013 0.7930 $50.51 ........... $10.10
11056.............. Trim skin lesions, 2 to 4. CH................ T................. 0013 0.7930 $50.51 ........... $10.10
11057.............. Trim skin lesions, over 4. CH................ T................. 0015 1.4595 $92.96 ........... $18.59
11100.............. Biopsy, skin lesion....... CH................ T................. 0013 0.7930 $50.51 ........... $10.10
11101.............. Biopsy, skin add-on....... CH................ T................. 0013 0.7930 $50.51 ........... $10.10
1110F.............. Pt lft inpt fac w/in 60 .................. M................. ........... ........... ........... ........... ...........
days.
1111F.............. Dschrg med/current med .................. M................. ........... ........... ........... ........... ...........
merge.
1116F.............. Auric/peri pain assessed.. .................. M................. ........... ........... ........... ........... ...........
1118F.............. GERD symps assessed 12 NI................ M................. ........... ........... ........... ........... ...........
month.
1119F.............. Init. Eval for condition.. NI................ M................. ........... ........... ........... ........... ...........
11200.............. Removal of skin tags...... .................. T................. 0013 0.7930 $50.51 ........... $10.10
11201.............. Remove skin tags add-on... .................. T................. 0015 1.4595 $92.96 ........... $18.59
1121F.............. Subs. Eval for condition.. NI................ M................. ........... ........... ........... ........... ...........
1123F.............. ACP discuss/dscn mkr doc'd NI................ M................. ........... ........... ........... ........... ...........
1124F.............. ACP discuss-no dscnmkr NI................ M................. ........... ........... ........... ........... ...........
doc'd.
1125F.............. Amnt Pain noted; pain NI................ M................. ........... ........... ........... ........... ...........
prsnt.
1126F.............. Amnt Pain noted; none NI................ M................. ........... ........... ........... ........... ...........
prsnt.
1127F.............. New episode for condition. NI................ M................. ........... ........... ........... ........... ...........
1128F.............. Subs. episode for NI................ M................. ........... ........... ........... ........... ...........
condition.
11300.............. Shave skin lesion......... CH................ T................. 0013 0.7930 $50.51 ........... $10.10
11301.............. Shave skin lesion......... CH................ T................. 0013 0.7930 $50.51 ........... $10.10
11302.............. Shave skin lesion......... .................. T................. 0013 0.7930 $50.51 ........... $10.10
11303.............. Shave skin lesion......... .................. T................. 0015 1.4595 $92.96 ........... $18.59
11305.............. Shave skin lesion......... .................. T................. 0013 0.7930 $50.51 ........... $10.10
11306.............. Shave skin lesion......... .................. T................. 0013 0.7930 $50.51 ........... $10.10
11307.............. Shave skin lesion......... .................. T................. 0013 0.7930 $50.51 ........... $10.10
11308.............. Shave skin lesion......... .................. T................. 0013 0.7930 $50.51 ........... $10.10
11310.............. Shave skin lesion......... .................. T................. 0013 0.7930 $50.51 ........... $10.10
11311.............. Shave skin lesion......... .................. T................. 0013 0.7930 $50.51 ........... $10.10
11312.............. Shave skin lesion......... .................. T................. 0013 0.7930 $50.51 ........... $10.10
11313.............. Shave skin lesion......... CH................ T................. 0013 0.7930 $50.51 ........... $10.10
11400.............. Exc tr-ext b9+marg 0.5 < .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
cm.
11401.............. Exc tr-ext b9+marg 0.6-1 .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
cm.
11402.............. Exc tr-ext b9+marg 1.1-2 .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
cm.
11403.............. Exc tr-ext b9+marg 2.1-3 .................. T................. 0020 8.6850 $553.18 ........... $110.64
cm.
11404.............. Exc tr-ext b9+marg 3.1-4 .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
cm.
11406.............. Exc tr-ext b9+marg > 4.0 .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
cm.
11420.............. Exc h-f-nk-sp b9+marg 0.5 .................. T................. 0020 8.6850 $553.18 ........... $110.64
<.
11421.............. Exc h-f-nk-sp b9+marg 0.6- .................. T................. 0020 8.6850 $553.18 ........... $110.64
1.
11422.............. Exc h-f-nk-sp b9+marg 1.1- .................. T................. 0020 8.6850 $553.18 ........... $110.64
2.
11423.............. Exc h-f-nk-sp b9+marg 2.1- .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
3.
11424.............. Exc h-f-nk-sp b9+marg 3.1- .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
4.
11426.............. Exc h-f-nk-sp b9+marg > 4 .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
cm.
11440.............. Exc face-mm b9+marg 0.5 < .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
cm.
11441.............. Exc face-mm b9+marg 0.6-1 .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
cm.
11442.............. Exc face-mm b9+marg 1.1-2 .................. T................. 0020 8.6850 $553.18 ........... $110.64
cm.
11443.............. Exc face-mm b9+marg 2.1-3 .................. T................. 0020 8.6850 $553.18 ........... $110.64
cm.
11444.............. Exc face-mm b9+marg 3.1-4 .................. T................. 0020 8.6850 $553.18 ........... $110.64
cm.
11446.............. Exc face-mm b9+marg > 4 cm .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
11450.............. Removal, sweat gland .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
lesion.
11451.............. Removal, sweat gland .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
lesion.
11462.............. Removal, sweat gland .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
lesion.
11463.............. Removal, sweat gland .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
lesion.
11470.............. Removal, sweat gland .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
lesion.
11471.............. Removal, sweat gland .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
lesion.
11600.............. Exc tr-ext mlg+marg 0.5 < .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
cm.
11601.............. Exc tr-ext mlg+marg 0.6-1 .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
cm.
11602.............. Exc tr-ext mlg+marg 1.1-2 .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
cm.
11603.............. Exc tr-ext mlg+marg 2.1-3 .................. T................. 0020 8.6850 $553.18 ........... $110.64
cm.
[[Page 67000]]
11604.............. Exc tr-ext mlg+marg 3.1-4 .................. T................. 0020 8.6850 $553.18 ........... $110.64
cm.
11606.............. Exc tr-ext mlg+marg > 4 cm .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
11620.............. Exc h-f-nk-sp mlg+marg 0.5 .................. T................. 0020 8.6850 $553.18 ........... $110.64
<.
11621.............. Exc h-f-nk-sp mlg+marg 0.6- .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
1.
11622.............. Exc h-f-nk-sp mlg+marg 1.1- .................. T................. 0020 8.6850 $553.18 ........... $110.64
2.
11623.............. Exc h-f-nk-sp mlg+marg 2.1- CH................ T................. 0020 8.6850 $553.18 ........... $110.64
3.
11624.............. Exc h-f-nk-sp mlg+marg 3.1- .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
4.
11626.............. Exc h-f-nk-sp mlg+mar > 4 .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
cm.
11640.............. Exc face-mm malig+marg 0.5 CH................ T................. 0019 4.3039 $274.13 $71.87 $54.83
<.
11641.............. Exc face-mm malig+marg 0.6- CH................ T................. 0019 4.3039 $274.13 $71.87 $54.83
1.
11642.............. Exc face-mm malig+marg 1.1- .................. T................. 0020 8.6850 $553.18 ........... $110.64
2.
11643.............. Exc face-mm malig+marg 2.1- .................. T................. 0020 8.6850 $553.18 ........... $110.64
3.
11644.............. Exc face-mm malig+marg 3.1- .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
4.
11646.............. Exc face-mm mlg+marg > 4 .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
cm.
11719.............. Trim nail(s).............. CH................ T................. 0013 0.7930 $50.51 ........... $10.10
11720.............. Debride nail, 1-5......... CH................ T................. 0013 0.7930 $50.51 ........... $10.10
11721.............. Debride nail, 6 or more... CH................ T................. 0013 0.7930 $50.51 ........... $10.10
11730.............. Removal of nail plate..... .................. T................. 0013 0.7930 $50.51 ........... $10.10
11732.............. Remove nail plate, add-on. CH................ T................. 0013 0.7930 $50.51 ........... $10.10
11740.............. Drain blood from under CH................ T................. 0012 0.2963 $18.87 ........... $3.77
nail.
11750.............. Removal of nail bed....... .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
11752.............. Remove nail bed/finger tip .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
11755.............. Biopsy, nail unit......... .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
11760.............. Repair of nail bed........ CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
11762.............. Reconstruction of nail bed CH................ T................. 0136 15.0458 $958.33 ........... $191.67
11765.............. Excision of nail fold, toe .................. T................. 0015 1.4595 $92.96 ........... $18.59
11770.............. Removal of pilonidal .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
lesion.
11771.............. Removal of pilonidal .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
lesion.
11772.............. Removal of pilonidal .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
lesion.
11900.............. Injection into skin CH................ T................. 0013 0.7930 $50.51 ........... $10.10
lesions.
11901.............. Added skin lesions CH................ T................. 0013 0.7930 $50.51 ........... $10.10
injection.
11920.............. Correct skin color defects CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
11921.............. Correct skin color defects CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
11922.............. Correct skin color defects CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
11950.............. Therapy for contour CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
defects.
11951.............. Therapy for contour CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
defects.
11952.............. Therapy for contour CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
defects.
11954.............. Therapy for contour CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
defects.
11960.............. Insert tissue expander(s). CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
11970.............. Replace tissue expander... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
11971.............. Remove tissue expander(s). .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
11975.............. Insert contraceptive cap.. .................. E................. ........... ........... ........... ........... ...........
11976.............. Removal of contraceptive .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
cap.
11977.............. Removal/reinsert contra .................. E................. ........... ........... ........... ........... ...........
cap.
11980.............. Implant hormone pellet(s). .................. X................. 0340 0.6310 $40.19 ........... $8.04
11981.............. Insert drug implant device .................. X................. 0340 0.6310 $40.19 ........... $8.04
11982.............. Remove drug implant device .................. X................. 0340 0.6310 $40.19 ........... $8.04
11983.............. Remove/insert drug implant .................. X................. 0340 0.6310 $40.19 ........... $8.04
12001.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12002.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12004.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12005.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12006.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12007.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12011.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12013.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12014.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12015.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12016.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12017.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12018.............. Repair superficial CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
wound(s).
12020.............. Closure of split wound.... CH................ T................. 0135 4.5263 $288.30 ........... $57.66
12021.............. Closure of split wound.... CH................ T................. 0135 4.5263 $288.30 ........... $57.66
12031.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12032.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12034.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12035.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12036.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12037.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12041.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12042.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12044.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12045.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12046.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12047.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12051.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12052.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12053.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12054.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12055.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
[[Page 67001]]
12056.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
12057.............. Layer closure of wound(s). CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
13100.............. Repair of wound or lesion. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
13101.............. Repair of wound or lesion. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
13102.............. Repair wound/lesion add-on CH................ T................. 0135 4.5263 $288.30 ........... $57.66
13120.............. Repair of wound or lesion. CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
13121.............. Repair of wound or lesion. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
13122.............. Repair wound/lesion add-on CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
13131.............. Repair of wound or lesion. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
13132.............. Repair of wound or lesion. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
13133.............. Repair wound/lesion add-on CH................ T................. 0135 4.5263 $288.30 ........... $57.66
13150.............. Repair of wound or lesion. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
13151.............. Repair of wound or lesion. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
13152.............. Repair of wound or lesion. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
13153.............. Repair wound/lesion add-on CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
13160.............. Late closure of wound..... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
14000.............. Skin tissue rearrangement. CH................ T................. 0136 15.0458 $958.33 ........... $191.67
14001.............. Skin tissue rearrangement. CH................ T................. 0136 15.0458 $958.33 ........... $191.67
14020.............. Skin tissue rearrangement. CH................ T................. 0136 15.0458 $958.33 ........... $191.67
14021.............. Skin tissue rearrangement. CH................ T................. 0136 15.0458 $958.33 ........... $191.67
14040.............. Skin tissue rearrangement. CH................ T................. 0136 15.0458 $958.33 ........... $191.67
14041.............. Skin tissue rearrangement. CH................ T................. 0136 15.0458 $958.33 ........... $191.67
14060.............. Skin tissue rearrangement. CH................ T................. 0136 15.0458 $958.33 ........... $191.67
14061.............. Skin tissue rearrangement. CH................ T................. 0136 15.0458 $958.33 ........... $191.67
14300.............. Skin tissue rearrangement. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
14350.............. Skin tissue rearrangement. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15002.............. Wnd prep, ch/inf, trk/arm/ CH................ T................. 0135 4.5263 $288.30 ........... $57.66
lg.
15003.............. Wnd prep, ch/inf addl 100 CH................ T................. 0135 4.5263 $288.30 ........... $57.66
cm.
15004.............. Wnd prep ch/inf, f/n/hf/g. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
15005.............. Wnd prep, f/n/hf/g, addl CH................ T................. 0135 4.5263 $288.30 ........... $57.66
cm.
15040.............. Harvest cultured skin CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
graft.
15050.............. Skin pinch graft.......... CH................ T................. 0135 4.5263 $288.30 ........... $57.66
15100.............. Skin splt grft, trnk/arm/ CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
leg.
15101.............. Skin splt grft t/a/l, add- CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
on.
15110.............. Epidrm autogrft trnk/arm/ CH................ T................. 0135 4.5263 $288.30 ........... $57.66
leg.
15111.............. Epidrm autogrft t/a/l add- CH................ T................. 0135 4.5263 $288.30 ........... $57.66
on.
15115.............. Epidrm a-grft face/nck/hf/ CH................ T................. 0135 4.5263 $288.30 ........... $57.66
g.
15116.............. Epidrm a-grft f/n/hf/g CH................ T................. 0135 4.5263 $288.30 ........... $57.66
addl.
15120.............. Skn splt a-grft fac/nck/hf/ CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
g.
15121.............. Skn splt a-grft f/n/hf/g CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
add.
15130.............. Derm autograft, trnk/arm/ CH................ T................. 0136 15.0458 $958.33 ........... $191.67
leg.
15131.............. Derm autograft t/a/l add- CH................ T................. 0136 15.0458 $958.33 ........... $191.67
on.
15135.............. Derm autograft face/nck/hf/ CH................ T................. 0136 15.0458 $958.33 ........... $191.67
g.
15136.............. Derm autograft, f/n/hf/g CH................ T................. 0136 15.0458 $958.33 ........... $191.67
add.
15150.............. Cult epiderm grft t/arm/ CH................ T................. 0135 4.5263 $288.30 ........... $57.66
leg.
15151.............. Cult epiderm grft t/a/l CH................ T................. 0135 4.5263 $288.30 ........... $57.66
addl.
15152.............. Cult epiderm graft t/a/l CH................ T................. 0135 4.5263 $288.30 ........... $57.66
+%.
15155.............. Cult epiderm graft, f/n/hf/ CH................ T................. 0135 4.5263 $288.30 ........... $57.66
g.
15156.............. Cult epidrm grft f/n/hfg CH................ T................. 0135 4.5263 $288.30 ........... $57.66
add.
15157.............. Cult epiderm grft f/n/hfg CH................ T................. 0135 4.5263 $288.30 ........... $57.66
+%.
15170.............. Acell graft trunk/arms/ CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
legs.
15171.............. Acell graft t/arm/leg add- CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
on.
15175.............. Acellular graft, f/n/hf/g. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
15176.............. Acell graft, f/n/hf/g add- CH................ T................. 0135 4.5263 $288.30 ........... $57.66
on.
15200.............. Skin full graft, trunk.... CH................ T................. 0136 15.0458 $958.33 ........... $191.67
15201.............. Skin full graft trunk add- CH................ T................. 0136 15.0458 $958.33 ........... $191.67
on.
15220.............. Skin full graft sclp/arm/ CH................ T................. 0136 15.0458 $958.33 ........... $191.67
leg.
15221.............. Skin full graft add-on.... CH................ T................. 0135 4.5263 $288.30 ........... $57.66
15240.............. Skin full grft face/genit/ CH................ T................. 0136 15.0458 $958.33 ........... $191.67
hf.
15241.............. Skin full graft add-on.... CH................ T................. 0135 4.5263 $288.30 ........... $57.66
15260.............. Skin full graft een & lips CH................ T................. 0136 15.0458 $958.33 ........... $191.67
15261.............. Skin full graft add-on.... CH................ T................. 0136 15.0458 $958.33 ........... $191.67
15300.............. Apply skinallogrft, t/arm/ CH................ T................. 0135 4.5263 $288.30 ........... $57.66
lg.
15301.............. Apply sknallogrft t/a/l CH................ T................. 0135 4.5263 $288.30 ........... $57.66
addl.
15320.............. Apply skin allogrft f/n/hf/ CH................ T................. 0135 4.5263 $288.30 ........... $57.66
g.
15321.............. Aply sknallogrft f/n/hfg CH................ T................. 0135 4.5263 $288.30 ........... $57.66
add.
15330.............. Aply acell alogrft t/arm/ CH................ T................. 0135 4.5263 $288.30 ........... $57.66
leg.
15331.............. Aply acell grft t/a/l add- CH................ T................. 0135 4.5263 $288.30 ........... $57.66
on.
15335.............. Apply acell graft, f/n/hf/ CH................ T................. 0135 4.5263 $288.30 ........... $57.66
g.
15336.............. Aply acell grft f/n/hf/g CH................ T................. 0135 4.5263 $288.30 ........... $57.66
add.
15340.............. Apply cult skin substitute CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
15341.............. Apply cult skin sub add-on CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
15360.............. Apply cult derm sub, t/a/l CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
15361.............. Aply cult derm sub t/a/l CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
add.
15365.............. Apply cult derm sub f/n/hf/ CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
g.
15366.............. Apply cult derm f/hf/g add CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
15400.............. Apply skin xenograft, t/a/ CH................ T................. 0135 4.5263 $288.30 ........... $57.66
l.
15401.............. Apply skn xenogrft t/a/l CH................ T................. 0135 4.5263 $288.30 ........... $57.66
add.
15420.............. Apply skin xgraft, f/n/hf/ CH................ T................. 0135 4.5263 $288.30 ........... $57.66
g.
15421.............. Apply skn xgrft f/n/hf/g CH................ T................. 0135 4.5263 $288.30 ........... $57.66
add.
[[Page 67002]]
15430.............. Apply acellular xenograft. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
15431.............. Apply acellular xgraft add CH................ T................. 0135 4.5263 $288.30 ........... $57.66
15570.............. Form skin pedicle flap.... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15572.............. Form skin pedicle flap.... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15574.............. Form skin pedicle flap.... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15576.............. Form skin pedicle flap.... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15600.............. Skin graft................ CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15610.............. Skin graft................ CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15620.............. Skin graft................ CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15630.............. Skin graft................ CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15650.............. Transfer skin pedicle flap CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15731.............. Forehead flap w/vasc CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
pedicle.
15732.............. Muscle-skin graft, head/ CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
neck.
15734.............. Muscle-skin graft, trunk.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15736.............. Muscle-skin graft, arm.... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15738.............. Muscle-skin graft, leg.... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15740.............. Island pedicle flap graft. CH................ T................. 0136 15.0458 $958.33 ........... $191.67
15750.............. Neurovascular pedicle CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
graft.
15756.............. Free myo/skin flap .................. C................. ........... ........... ........... ........... ...........
microvasc.
15757.............. Free skin flap, microvasc. .................. C................. ........... ........... ........... ........... ...........
15758.............. Free fascial flap, .................. C................. ........... ........... ........... ........... ...........
microvasc.
15760.............. Composite skin graft...... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15770.............. Derma-fat-fascia graft.... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15775.............. Hair transplant punch CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
grafts.
15776.............. Hair transplant punch CH................ T................. 0133 1.2792 $81.48 $25.67 $16.30
grafts.
15780.............. Abrasion treatment of skin .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
15781.............. Abrasion treatment of skin .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
15782.............. Abrasion treatment of skin .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
15783.............. Abrasion treatment of skin .................. T................. 0016 2.6604 $169.45 ........... $33.89
15786.............. Abrasion, lesion, single.. .................. T................. 0013 0.7930 $50.51 ........... $10.10
15787.............. Abrasion, lesions, add-on. .................. T................. 0013 0.7930 $50.51 ........... $10.10
15788.............. Chemical peel, face, CH................ T................. 0013 0.7930 $50.51 ........... $10.10
epiderm.
15789.............. Chemical peel, face, .................. T................. 0015 1.4595 $92.96 ........... $18.59
dermal.
15792.............. Chemical peel, nonfacial.. CH................ T................. 0015 1.4595 $92.96 ........... $18.59
15793.............. Chemical peel, nonfacial.. CH................ T................. 0013 0.7930 $50.51 ........... $10.10
15819.............. Plastic surgery, neck..... CH................ T................. 0134 2.1051 $134.08 $42.24 $26.82
15820.............. Revision of lower eyelid.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15821.............. Revision of lower eyelid.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15822.............. Revision of upper eyelid.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15823.............. Revision of upper eyelid.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15824.............. Removal of forehead CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
wrinkles.
15825.............. Removal of neck wrinkles.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15826.............. Removal of brow wrinkles.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15828.............. Removal of face wrinkles.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15829.............. Removal of skin wrinkles.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15830.............. Exc skin abd.............. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
15832.............. Excise excessive skin .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
tissue.
15833.............. Excise excessive skin .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
tissue.
15834.............. Excise excessive skin .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
tissue.
15835.............. Excise excessive skin CH................ T................. 0022 21.1098 $1,344.57 $354.45 $268.91
tissue.
15836.............. Excise excessive skin .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
tissue.
15837.............. Excise excessive skin .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
tissue.
15838.............. Excise excessive skin .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
tissue.
15839.............. Excise excessive skin .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
tissue.
15840.............. Graft for face nerve palsy CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15841.............. Graft for face nerve palsy CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15842.............. Flap for face nerve palsy. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15845.............. Skin and muscle repair, CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
face.
15847.............. Exc skin abd add-on....... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
15850.............. Removal of sutures........ .................. T................. 0016 2.6604 $169.45 ........... $33.89
15851.............. Removal of sutures........ .................. T................. 0016 2.6604 $169.45 ........... $33.89
15852.............. Dressing change not for .................. X................. 0340 0.6310 $40.19 ........... $8.04
burn.
15860.............. Test for blood flow in .................. X................. 0340 0.6310 $40.19 ........... $8.04
graft.
15876.............. Suction assisted lipectomy CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15877.............. Suction assisted lipectomy CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15878.............. Suction assisted lipectomy CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15879.............. Suction assisted lipectomy CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15920.............. Removal of tail bone ulcer .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
15922.............. Removal of tail bone ulcer CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15931.............. Remove sacrum pressure .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
sore.
15933.............. Remove sacrum pressure .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
sore.
15934.............. Remove sacrum pressure CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
sore.
15935.............. Remove sacrum pressure CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
sore.
15936.............. Remove sacrum pressure CH................ T................. 0136 15.0458 $958.33 ........... $191.67
sore.
15937.............. Remove sacrum pressure CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
sore.
15940.............. Remove hip pressure sore.. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
15941.............. Remove hip pressure sore.. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
15944.............. Remove hip pressure sore.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15945.............. Remove hip pressure sore.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
15946.............. Remove hip pressure sore.. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
[[Page 67003]]
15950.............. Remove thigh pressure sore .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
15951.............. Remove thigh pressure sore .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
15952.............. Remove thigh pressure sore CH................ T................. 0136 15.0458 $958.33 ........... $191.67
15953.............. Remove thigh pressure sore CH................ T................. 0136 15.0458 $958.33 ........... $191.67
15956.............. Remove thigh pressure sore CH................ T................. 0136 15.0458 $958.33 ........... $191.67
15958.............. Remove thigh pressure sore CH................ T................. 0136 15.0458 $958.33 ........... $191.67
15999.............. Removal of pressure sore.. .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
16000.............. Initial treatment of CH................ T................. 0013 0.7930 $50.51 ........... $10.10
burn(s).
16020.............. Dress/debrid p-thick burn, CH................ T................. 0015 1.4595 $92.96 ........... $18.59
s.
16025.............. Dress/debrid p-thick burn, CH................ T................. 0016 2.6604 $169.45 ........... $33.89
m.
16030.............. Dress/debrid p-thick burn, CH................ T................. 0016 2.6604 $169.45 ........... $33.89
l.
16035.............. Incision of burn scab, .................. T................. 0016 2.6604 $169.45 ........... $33.89
initi.
16036.............. Escharotomy; add'l .................. C................. ........... ........... ........... ........... ...........
incision.
17000.............. Destruct premalg lesion... CH................ T................. 0013 0.7930 $50.51 ........... $10.10
17003.............. Destruct premalg les, 2-14 CH................ T................. 0012 0.2963 $18.87 ........... $3.77
17004.............. Destroy premlg lesions 15+ CH................ T................. 0016 2.6604 $169.45 ........... $33.89
17106.............. Destruction of skin CH................ T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17107.............. Destruction of skin CH................ T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17108.............. Destruction of skin CH................ T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17110.............. Destruct b9 lesion, 1-14.. CH................ T................. 0013 0.7930 $50.51 ........... $10.10
17111.............. Destruct lesion, 15 or CH................ T................. 0015 1.4595 $92.96 ........... $18.59
more.
17250.............. Chemical cautery, tissue.. CH................ T................. 0015 1.4595 $92.96 ........... $18.59
17260.............. Destruction of skin .................. T................. 0015 1.4595 $92.96 ........... $18.59
lesions.
17261.............. Destruction of skin .................. T................. 0015 1.4595 $92.96 ........... $18.59
lesions.
17262.............. Destruction of skin .................. T................. 0015 1.4595 $92.96 ........... $18.59
lesions.
17263.............. Destruction of skin .................. T................. 0015 1.4595 $92.96 ........... $18.59
lesions.
17264.............. Destruction of skin .................. T................. 0015 1.4595 $92.96 ........... $18.59
lesions.
17266.............. Destruction of skin .................. T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17270.............. Destruction of skin .................. T................. 0015 1.4595 $92.96 ........... $18.59
lesions.
17271.............. Destruction of skin CH................ T................. 0015 1.4595 $92.96 ........... $18.59
lesions.
17272.............. Destruction of skin .................. T................. 0015 1.4595 $92.96 ........... $18.59
lesions.
17273.............. Destruction of skin CH................ T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17274.............. Destruction of skin .................. T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17276.............. Destruction of skin .................. T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17280.............. Destruction of skin .................. T................. 0015 1.4595 $92.96 ........... $18.59
lesions.
17281.............. Destruction of skin CH................ T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17282.............. Destruction of skin CH................ T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17283.............. Destruction of skin CH................ T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17284.............. Destruction of skin .................. T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17286.............. Destruction of skin CH................ T................. 0016 2.6604 $169.45 ........... $33.89
lesions.
17311.............. Mohs, 1 stage, h/n/hf/g... .................. T................. 0694 3.6321 $231.34 $91.69 $46.27
17312.............. Mohs addl stage........... .................. T................. 0694 3.6321 $231.34 $91.69 $46.27
17313.............. Mohs, 1 stage, t/a/l...... .................. T................. 0694 3.6321 $231.34 $91.69 $46.27
17314.............. Mohs, addl stage, t/a/l... .................. T................. 0694 3.6321 $231.34 $91.69 $46.27
17315.............. Mohs surg, addl block..... .................. T................. 0694 3.6321 $231.34 $91.69 $46.27
17340.............. Cryotherapy of skin....... CH................ T................. 0013 0.7930 $50.51 ........... $10.10
17360.............. Skin peel therapy......... .................. T................. 0013 0.7930 $50.51 ........... $10.10
17380.............. Hair removal by .................. T................. 0013 0.7930 $50.51 ........... $10.10
electrolysis.
17999.............. Skin tissue procedure..... .................. T................. 0012 0.2963 $18.87 ........... $3.77
19000.............. Drainage of breast lesion. .................. T................. 0004 4.3270 $275.60 ........... $55.12
19001.............. Drain breast lesion add-on .................. T................. 0002 1.1097 $70.68 ........... $14.14
19020.............. Incision of breast lesion. .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
19030.............. Injection for breast x-ray .................. N................. ........... ........... ........... ........... ...........
19100.............. Bx breast percut w/o image CH................ T................. 0004 4.3270 $275.60 ........... $55.12
19101.............. Biopsy of breast, open.... .................. T................. 0028 20.6417 $1,314.75 $303.74 $262.95
19102.............. Bx breast percut w/image.. .................. T................. 0005 7.1147 $453.16 ........... $90.63
19103.............. Bx breast percut w/device. CH................ T................. 0037 13.5764 $864.74 $228.76 $172.95
19105.............. Cryosurg ablate fa, each.. .................. T................. 0029 31.7134 $2,019.95 $581.52 $403.99
19110.............. Nipple exploration........ .................. T................. 0028 20.6417 $1,314.75 $303.74 $262.95
19112.............. Excise breast duct fistula .................. T................. 0028 20.6417 $1,314.75 $303.74 $262.95
19120.............. Removal of breast lesion.. .................. T................. 0028 20.6417 $1,314.75 $303.74 $262.95
19125.............. Excision, breast lesion... .................. T................. 0028 20.6417 $1,314.75 $303.74 $262.95
19126.............. Excision, addl breast .................. T................. 0028 20.6417 $1,314.75 $303.74 $262.95
lesion.
19260.............. Removal of chest wall .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
lesion.
19271.............. Revision of chest wall.... .................. C................. ........... ........... ........... ........... ...........
19272.............. Extensive chest wall .................. C................. ........... ........... ........... ........... ...........
surgery.
19290.............. Place needle wire, breast. .................. N................. ........... ........... ........... ........... ...........
19291.............. Place needle wire, breast. .................. N................. ........... ........... ........... ........... ...........
19295.............. Place breast clip, percut. CH................ N................. ........... ........... ........... ........... ...........
19296.............. Place po breast cath for .................. T................. 0648 56.5774 $3,603.64 ........... $720.73
rad.
19297.............. Place breast cath for rad. .................. T................. 0648 56.5774 $3,603.64 ........... $720.73
19298.............. Place breast rad tube/ CH................ T................. 0648 56.5774 $3,603.64 ........... $720.73
caths.
19300.............. Removal of breast tissue.. .................. T................. 0028 20.6417 $1,314.75 $303.74 $262.95
19301.............. Partical mastectomy....... .................. T................. 0028 20.6417 $1,314.75 $303.74 $262.95
19302.............. P-mastectomy w/ln removal. CH................ T................. 0030 39.8191 $2,536.24 $747.07 $507.25
19303.............. Mast, simple, complete.... .................. T................. 0029 31.7134 $2,019.95 $581.52 $403.99
19304.............. Mast, subq................ .................. T................. 0029 31.7134 $2,019.95 $581.52 $403.99
19305.............. Mast, radical............. .................. C................. ........... ........... ........... ........... ...........
19306.............. Mast, rad, urban type..... .................. C................. ........... ........... ........... ........... ...........
19307.............. Mast, mod rad............. .................. T................. 0030 39.8191 $2,536.24 $747.07 $507.25
[[Page 67004]]
19316.............. Suspension of breast...... .................. T................. 0029 31.7134 $2,019.95 $581.52 $403.99
19318.............. Reduction of large breast. CH................ T................. 0030 39.8191 $2,536.24 $747.07 $507.25
19324.............. Enlarge breast............ CH................ T................. 0030 39.8191 $2,536.24 $747.07 $507.25
19325.............. Enlarge breast with .................. T................. 0648 56.5774 $3,603.64 ........... $720.73
implant.
19328.............. Removal of breast implant. .................. T................. 0029 31.7134 $2,019.95 $581.52 $403.99
19330.............. Removal of implant .................. T................. 0029 31.7134 $2,019.95 $581.52 $403.99
material.
19340.............. Immediate breast .................. T................. 0030 39.8191 $2,536.24 $747.07 $507.25
prosthesis.
19342.............. Delayed breast prosthesis. .................. T................. 0648 56.5774 $3,603.64 ........... $720.73
19350.............. Breast reconstruction..... .................. T................. 0028 20.6417 $1,314.75 $303.74 $262.95
19355.............. Correct inverted nipple(s) .................. T................. 0029 31.7134 $2,019.95 $581.52 $403.99
19357.............. Breast reconstruction..... .................. T................. 0648 56.5774 $3,603.64 ........... $720.73
19361.............. Breast reconstr w/lat flap .................. C................. ........... ........... ........... ........... ...........
19364.............. Breast reconstruction..... .................. C................. ........... ........... ........... ........... ...........
19366.............. Breast reconstruction..... .................. T................. 0029 31.7134 $2,019.95 $581.52 $403.99
19367.............. Breast reconstruction..... .................. C................. ........... ........... ........... ........... ...........
19368.............. Breast reconstruction..... .................. C................. ........... ........... ........... ........... ...........
19369.............. Breast reconstruction..... .................. C................. ........... ........... ........... ........... ...........
19370.............. Surgery of breast capsule. .................. T................. 0029 31.7134 $2,019.95 $581.52 $403.99
19371.............. Removal of breast capsule. .................. T................. 0029 31.7134 $2,019.95 $581.52 $403.99
19380.............. Revise breast .................. T................. 0030 39.8191 $2,536.24 $747.07 $507.25
reconstruction.
19396.............. Design custom breast .................. T................. 0029 31.7134 $2,019.95 $581.52 $403.99
implant.
19499.............. Breast surgery procedure.. .................. T................. 0028 20.6417 $1,314.75 $303.74 $262.95
20000.............. Incision of abscess....... .................. T................. 0006 1.4066 $89.59 ........... $17.92
20005.............. Incision of deep abscess.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
2000F.............. Blood pressure measure.... .................. M................. ........... ........... ........... ........... ...........
2001F.............. Weight recorded........... .................. M................. ........... ........... ........... ........... ...........
2002F.............. Clin sign vol ovrld assess .................. M................. ........... ........... ........... ........... ...........
2004F.............. Initial exam involved .................. M................. ........... ........... ........... ........... ...........
joints.
20100.............. Explore wound, neck....... .................. T................. 0023 9.6341 $613.63 ........... $122.73
20101.............. Explore wound, chest...... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
20102.............. Explore wound, abdomen.... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
20103.............. Explore wound, extremity.. .................. T................. 0023 9.6341 $613.63 ........... $122.73
2010F.............. Vital signs recorded...... .................. M................. ........... ........... ........... ........... ...........
2014F.............. Mental status assess...... .................. M................. ........... ........... ........... ........... ...........
20150.............. Excise epiphyseal bar..... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
2018F.............. Hydration status assess... .................. M................. ........... ........... ........... ........... ...........
2019F.............. Dilated macul exam done... .................. M................. ........... ........... ........... ........... ...........
20200.............. Muscle biopsy............. .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
20205.............. Deep muscle biopsy........ .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
20206.............. Needle biopsy, muscle..... .................. T................. 0005 7.1147 $453.16 ........... $90.63
2020F.............. Dilated fundus eval done.. .................. M................. ........... ........... ........... ........... ...........
2021F.............. Dilat macul+ exam done.... .................. M................. ........... ........... ........... ........... ...........
20220.............. Bone biopsy, trocar/needle CH................ T................. 0020 8.6850 $553.18 ........... $110.64
20225.............. Bone biopsy, trocar/needle .................. T................. 0020 8.6850 $553.18 ........... $110.64
2022F.............. Dil retina exam interp rev .................. M................. ........... ........... ........... ........... ...........
20240.............. Bone biopsy, excisional... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
20245.............. Bone biopsy, excisional... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
2024F.............. 7 field photo interp doc .................. M................. ........... ........... ........... ........... ...........
rev.
20250.............. Open bone biopsy.......... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
20251.............. Open bone biopsy.......... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
2026F.............. Eye image valid to dx rev. .................. M................. ........... ........... ........... ........... ...........
2027F.............. Optic nerve head eval done .................. M................. ........... ........... ........... ........... ...........
2028F.............. Foot exam performed....... .................. M................. ........... ........... ........... ........... ...........
2029F.............. Complete phys skin exam .................. M................. ........... ........... ........... ........... ...........
done.
2030F.............. H2O stat doc'd, normal.... .................. M................. ........... ........... ........... ........... ...........
2031F.............. H2O stat doc'd, dehydrated .................. M................. ........... ........... ........... ........... ...........
2035F.............. Tymp memb motion exam'd... .................. M................. ........... ........... ........... ........... ...........
20500.............. Injection of sinus tract.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
20501.............. Inject sinus tract for x- .................. N................. ........... ........... ........... ........... ...........
ray.
20520.............. Removal of foreign body... .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
20525.............. Removal of foreign body... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
20526.............. Ther injection, carp .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
tunnel.
20550.............. Inj tendon sheath/ligament .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
20551.............. Inj tendon origin/ .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
insertion.
20552.............. Inj trigger point, 1/2 .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
muscl.
20553.............. Inject trigger points, =/> .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
3.
20555.............. Place ndl musc/tis for rt. NI................ T................. 0050 29.1900 $1,859.23 ........... $371.85
20600.............. Drain/inject, joint/bursa. .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
20605.............. Drain/inject, joint/bursa. .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
20610.............. Drain/inject, joint/bursa. .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
20612.............. Aspirate/inj ganglion cyst .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
20615.............. Treatment of bone cyst.... .................. T................. 0004 4.3270 $275.60 ........... $55.12
20650.............. Insert and remove bone pin .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
20660.............. Apply, rem fixation device .................. C................. ........... ........... ........... ........... ...........
20661.............. Application of head brace. .................. C................. ........... ........... ........... ........... ...........
20662.............. Application of pelvis .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
brace.
20663.............. Application of thigh brace .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
20664.............. Halo brace application.... .................. C................. ........... ........... ........... ........... ...........
20665.............. Removal of fixation device .................. X................. 0340 0.6310 $40.19 ........... $8.04
20670.............. Removal of support implant .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
[[Page 67005]]
20680.............. Removal of support implant .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
20690.............. Apply bone fixation device .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
20692.............. Apply bone fixation device .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
20693.............. Adjust bone fixation .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
device.
20694.............. Remove bone fixation .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
device.
20802.............. Replantation, arm, .................. C................. ........... ........... ........... ........... ...........
complete.
20805.............. Replant forearm, complete. .................. C................. ........... ........... ........... ........... ...........
20808.............. Replantation hand, .................. C................. ........... ........... ........... ........... ...........
complete.
20816.............. Replantation digit, .................. C................. ........... ........... ........... ........... ...........
complete.
20822.............. Replantation digit, .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
complete.
20824.............. Replantation thumb, .................. C................. ........... ........... ........... ........... ...........
complete.
20827.............. Replantation thumb, .................. C................. ........... ........... ........... ........... ...........
complete.
20838.............. Replantation foot, .................. C................. ........... ........... ........... ........... ...........
complete.
20900.............. Removal of bone for graft. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
20902.............. Removal of bone for graft. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
20910.............. Remove cartilage for graft CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
20912.............. Remove cartilage for graft CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
20920.............. Removal of fascia for CH................ T................. 0136 15.0458 $958.33 ........... $191.67
graft.
20922.............. Removal of fascia for CH................ T................. 0136 15.0458 $958.33 ........... $191.67
graft.
20924.............. Removal of tendon for .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
graft.
20926.............. Removal of tissue for CH................ T................. 0135 4.5263 $288.30 ........... $57.66
graft.
20930.............. Sp bone algrft morsel add- .................. C................. ........... ........... ........... ........... ...........
on.
20931.............. Sp bone algrft struct add- .................. C................. ........... ........... ........... ........... ...........
on.
20936.............. Sp bone agrft local add-on .................. C................. ........... ........... ........... ........... ...........
20937.............. Sp bone agrft morsel add- .................. C................. ........... ........... ........... ........... ...........
on.
20938.............. Sp bone agrft struct add- .................. C................. ........... ........... ........... ........... ...........
on.
20950.............. Fluid pressure, muscle.... .................. T................. 0006 1.4066 $89.59 ........... $17.92
20955.............. Fibula bone graft, .................. C................. ........... ........... ........... ........... ...........
microvasc.
20956.............. Iliac bone graft, .................. C................. ........... ........... ........... ........... ...........
microvasc.
20957.............. Mt bone graft, microvasc.. .................. C................. ........... ........... ........... ........... ...........
20962.............. Other bone graft, .................. C................. ........... ........... ........... ........... ...........
microvasc.
20969.............. Bone/skin graft, microvasc .................. C................. ........... ........... ........... ........... ...........
20970.............. Bone/skin graft, iliac .................. C................. ........... ........... ........... ........... ...........
crest.
20972.............. Bone/skin graft, .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
metatarsal.
20973.............. Bone/skin graft, great toe .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
20974.............. Electrical bone .................. A................. ........... ........... ........... ........... ...........
stimulation.
20975.............. Electrical bone CH................ N................. ........... ........... ........... ........... ...........
stimulation.
20979.............. Us bone stimulation....... .................. X................. 0340 0.6310 $40.19 ........... $8.04
20982.............. Ablate, bone tumor(s) perq .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
20985.............. Cptr-asst dir ms px....... NI................ N................. ........... ........... ........... ........... ...........
20986.............. Cptr-asst dir ms px io img NI................ N................. ........... ........... ........... ........... ...........
20987.............. Cptr-asst dir ms px pre NI................ N................. ........... ........... ........... ........... ...........
img.
20999.............. Musculoskeletal surgery... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
21010.............. Incision of jaw joint..... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21015.............. Resection of facial tumor. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
21025.............. Excision of bone, lower .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
jaw.
21026.............. Excision of facial bone(s) .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21029.............. Contour of face bone .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
lesion.
21030.............. Excise max/zygoma b9 tumor .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21031.............. Remove exostosis, mandible .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21032.............. Remove exostosis, maxilla. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21034.............. Excise max/zygoma mlg .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
tumor.
21040.............. Excise mandible lesion.... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21044.............. Removal of jaw bone lesion .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21045.............. Extensive jaw surgery..... .................. C................. ........... ........... ........... ........... ...........
21046.............. Remove mandible cyst .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
complex.
21047.............. Excise lwr jaw cyst w/ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
repair.
21048.............. Remove maxilla cyst .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
complex.
21049.............. Excis uppr jaw cyst w/ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
repair.
21050.............. Removal of jaw joint...... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21060.............. Remove jaw joint cartilage .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21070.............. Remove coronoid process... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21073.............. Mnpj of tmj w/anesth...... NI................ T................. 0252 7.4474 $474.35 $109.16 $94.87
21076.............. Prepare face/oral .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
prosthesis.
21077.............. Prepare face/oral .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
prosthesis.
21079.............. Prepare face/oral .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
prosthesis.
21080.............. Prepare face/oral .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
prosthesis.
21081.............. Prepare face/oral .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
prosthesis.
21082.............. Prepare face/oral .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
prosthesis.
21083.............. Prepare face/oral .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
prosthesis.
21084.............. Prepare face/oral .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
prosthesis.
21085.............. Prepare face/oral .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
prosthesis.
21086.............. Prepare face/oral .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
prosthesis.
21087.............. Prepare face/oral .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
prosthesis.
21088.............. Prepare face/oral .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
prosthesis.
21089.............. Prepare face/oral .................. T................. 0251 2.5002 $159.25 ........... $31.85
prosthesis.
21100.............. Maxillofacial fixation.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21110.............. Interdental fixation...... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
21116.............. Injection, jaw joint x-ray .................. N................. ........... ........... ........... ........... ...........
21120.............. Reconstruction of chin.... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
[[Page 67006]]
21121.............. Reconstruction of chin.... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21122.............. Reconstruction of chin.... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21123.............. Reconstruction of chin.... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21125.............. Augmentation, lower jaw .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
bone.
21127.............. Augmentation, lower jaw .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
bone.
21137.............. Reduction of forehead..... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21138.............. Reduction of forehead..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21139.............. Reduction of forehead..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21141.............. Reconstruct midface, .................. C................. ........... ........... ........... ........... ...........
lefort.
21142.............. Reconstruct midface, .................. C................. ........... ........... ........... ........... ...........
lefort.
21143.............. Reconstruct midface, .................. C................. ........... ........... ........... ........... ...........
lefort.
21145.............. Reconstruct midface, .................. C................. ........... ........... ........... ........... ...........
lefort.
21146.............. Reconstruct midface, .................. C................. ........... ........... ........... ........... ...........
lefort.
21147.............. Reconstruct midface, .................. C................. ........... ........... ........... ........... ...........
lefort.
21150.............. Reconstruct midface, .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
lefort.
21151.............. Reconstruct midface, .................. C................. ........... ........... ........... ........... ...........
lefort.
21154.............. Reconstruct midface, .................. C................. ........... ........... ........... ........... ...........
lefort.
21155.............. Reconstruct midface, .................. C................. ........... ........... ........... ........... ...........
lefort.
21159.............. Reconstruct midface, .................. C................. ........... ........... ........... ........... ...........
lefort.
21160.............. Reconstruct midface, .................. C................. ........... ........... ........... ........... ...........
lefort.
21172.............. Reconstruct orbit/forehead .................. C................. ........... ........... ........... ........... ...........
21175.............. Reconstruct orbit/forehead .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21179.............. Reconstruct entire .................. C................. ........... ........... ........... ........... ...........
forehead.
21180.............. Reconstruct entire .................. C................. ........... ........... ........... ........... ...........
forehead.
21181.............. Contour cranial bone .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
lesion.
21182.............. Reconstruct cranial bone.. .................. C................. ........... ........... ........... ........... ...........
21183.............. Reconstruct cranial bone.. .................. C................. ........... ........... ........... ........... ...........
21184.............. Reconstruct cranial bone.. .................. C................. ........... ........... ........... ........... ...........
21188.............. Reconstruction of midface. .................. C................. ........... ........... ........... ........... ...........
21193.............. Reconst lwr jaw w/o graft. .................. C................. ........... ........... ........... ........... ...........
21194.............. Reconst lwr jaw w/graft... .................. C................. ........... ........... ........... ........... ...........
21195.............. Reconst lwr jaw w/o .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
fixation.
21196.............. Reconst lwr jaw w/fixation .................. C................. ........... ........... ........... ........... ...........
21198.............. Reconstr lwr jaw segment.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21199.............. Reconstr lwr jaw w/advance .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21206.............. Reconstruct upper jaw bone .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21208.............. Augmentation of facial .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
bones.
21209.............. Reduction of facial bones. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21210.............. Face bone graft........... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21215.............. Lower jaw bone graft...... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21230.............. Rib cartilage graft....... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21235.............. Ear cartilage graft....... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21240.............. Reconstruction of jaw .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
joint.
21242.............. Reconstruction of jaw .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
joint.
21243.............. Reconstruction of jaw .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
joint.
21244.............. Reconstruction of lower .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
jaw.
21245.............. Reconstruction of jaw..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21246.............. Reconstruction of jaw..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21247.............. Reconstruct lower jaw bone .................. C................. ........... ........... ........... ........... ...........
21248.............. Reconstruction of jaw..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21249.............. Reconstruction of jaw..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21255.............. Reconstruct lower jaw bone .................. C................. ........... ........... ........... ........... ...........
21256.............. Reconstruction of orbit... .................. C................. ........... ........... ........... ........... ...........
21260.............. Revise eye sockets........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21261.............. Revise eye sockets........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21263.............. Revise eye sockets........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21267.............. Revise eye sockets........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21268.............. Revise eye sockets........ .................. C................. ........... ........... ........... ........... ...........
21270.............. Augmentation, cheek bone.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21275.............. Revision, orbitofacial .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
bones.
21280.............. Revision of eyelid........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21282.............. Revision of eyelid........ .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
21295.............. Revision of jaw muscle/ .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
bone.
21296.............. Revision of jaw muscle/ .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
bone.
21299.............. Cranio/maxillofacial .................. T................. 0251 2.5002 $159.25 ........... $31.85
surgery.
21310.............. Treatment of nose fracture .................. T................. 0251 2.5002 $159.25 ........... $31.85
21315.............. Treatment of nose fracture .................. T................. 0251 2.5002 $159.25 ........... $31.85
21320.............. Treatment of nose fracture CH................ T................. 0253 16.3288 $1,040.05 $282.29 $208.01
21325.............. Treatment of nose fracture .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21330.............. Treatment of nose fracture .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21335.............. Treatment of nose fracture .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21336.............. Treat nasal septal CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
fracture.
21337.............. Treat nasal septal .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
fracture.
21338.............. Treat nasoethmoid fracture .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21339.............. Treat nasoethmoid fracture .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21340.............. Treatment of nose fracture .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21343.............. Treatment of sinus .................. C................. ........... ........... ........... ........... ...........
fracture.
21344.............. Treatment of sinus .................. C................. ........... ........... ........... ........... ...........
fracture.
21345.............. Treat nose/jaw fracture... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21346.............. Treat nose/jaw fracture... .................. C................. ........... ........... ........... ........... ...........
[[Page 67007]]
21347.............. Treat nose/jaw fracture... .................. C................. ........... ........... ........... ........... ...........
21348.............. Treat nose/jaw fracture... .................. C................. ........... ........... ........... ........... ...........
21355.............. Treat cheek bone fracture. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21356.............. Treat cheek bone fracture. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21360.............. Treat cheek bone fracture. CH................ T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21365.............. Treat cheek bone fracture. CH................ T................. 0256 39.8776 $2,539.96 ........... $507.99
21366.............. Treat cheek bone fracture. .................. C................. ........... ........... ........... ........... ...........
21385.............. Treat eye socket fracture. CH................ T................. 0256 39.8776 $2,539.96 ........... $507.99
21386.............. Treat eye socket fracture. .................. C................. ........... ........... ........... ........... ...........
21387.............. Treat eye socket fracture. .................. C................. ........... ........... ........... ........... ...........
21390.............. Treat eye socket fracture. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21395.............. Treat eye socket fracture. .................. C................. ........... ........... ........... ........... ...........
21400.............. Treat eye socket fracture. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
21401.............. Treat eye socket fracture. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
21406.............. Treat eye socket fracture. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21407.............. Treat eye socket fracture. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21408.............. Treat eye socket fracture. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21421.............. Treat mouth roof fracture. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21422.............. Treat mouth roof fracture. .................. C................. ........... ........... ........... ........... ...........
21423.............. Treat mouth roof fracture. .................. C................. ........... ........... ........... ........... ...........
21431.............. Treat craniofacial .................. C................. ........... ........... ........... ........... ...........
fracture.
21432.............. Treat craniofacial .................. C................. ........... ........... ........... ........... ...........
fracture.
21433.............. Treat craniofacial .................. C................. ........... ........... ........... ........... ...........
fracture.
21435.............. Treat craniofacial .................. C................. ........... ........... ........... ........... ...........
fracture.
21436.............. Treat craniofacial .................. C................. ........... ........... ........... ........... ...........
fracture.
21440.............. Treat dental ridge .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
fracture.
21445.............. Treat dental ridge .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
fracture.
21450.............. Treat lower jaw fracture.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
21451.............. Treat lower jaw fracture.. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
21452.............. Treat lower jaw fracture.. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
21453.............. Treat lower jaw fracture.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21454.............. Treat lower jaw fracture.. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
21461.............. Treat lower jaw fracture.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21462.............. Treat lower jaw fracture.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21465.............. Treat lower jaw fracture.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21470.............. Treat lower jaw fracture.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21480.............. Reset dislocated jaw...... .................. T................. 0251 2.5002 $159.25 ........... $31.85
21485.............. Reset dislocated jaw...... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
21490.............. Repair dislocated jaw..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
21495.............. Treat hyoid bone fracture. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
21497.............. Interdental wiring........ .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
21499.............. Head surgery procedure.... .................. T................. 0251 2.5002 $159.25 ........... $31.85
21501.............. Drain neck/chest lesion... .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
21502.............. Drain chest lesion........ .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
21510.............. Drainage of bone lesion... .................. C................. ........... ........... ........... ........... ...........
21550.............. Biopsy of neck/chest...... .................. T................. 0020 8.6850 $553.18 ........... $110.64
21555.............. Remove lesion, neck/chest. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
21556.............. Remove lesion, neck/chest. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
21557.............. Remove tumor, neck/chest.. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
21600.............. Partial removal of rib.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
21610.............. Partial removal of rib.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
21615.............. Removal of rib............ .................. C................. ........... ........... ........... ........... ...........
21616.............. Removal of rib and nerves. .................. C................. ........... ........... ........... ........... ...........
21620.............. Partial removal of sternum .................. C................. ........... ........... ........... ........... ...........
21627.............. Sternal debridement....... .................. C................. ........... ........... ........... ........... ...........
21630.............. Extensive sternum surgery. .................. C................. ........... ........... ........... ........... ...........
21632.............. Extensive sternum surgery. .................. C................. ........... ........... ........... ........... ...........
21685.............. Hyoid myotomy & suspension .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
21700.............. Revision of neck muscle... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
21705.............. Revision of neck muscle/ .................. C................. ........... ........... ........... ........... ...........
rib.
21720.............. Revision of neck muscle... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
21725.............. Revision of neck muscle... .................. T................. 0006 1.4066 $89.59 ........... $17.92
21740.............. Reconstruction of sternum. .................. C................. ........... ........... ........... ........... ...........
21742.............. Repair stern/nuss w/o .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
scope.
21743.............. Repair sternum/nuss w/ .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
scope.
21750.............. Repair of sternum .................. C................. ........... ........... ........... ........... ...........
separation.
21800.............. Treatment of rib fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
21805.............. Treatment of rib fracture. .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
21810.............. Treatment of rib .................. C................. ........... ........... ........... ........... ...........
fracture(s).
21820.............. Treat sternum fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
21825.............. Treat sternum fracture.... .................. C................. ........... ........... ........... ........... ...........
21899.............. Neck/chest surgery .................. T................. 0251 2.5002 $159.25 ........... $31.85
procedure.
21920.............. Biopsy soft tissue of back .................. T................. 0020 8.6850 $553.18 ........... $110.64
21925.............. Biopsy soft tissue of back .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
21930.............. Remove lesion, back or .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
flank.
21935.............. Remove tumor, back........ .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
22010.............. I&d, p-spine, c/t/cerv- .................. C................. ........... ........... ........... ........... ...........
thor.
22015.............. I&d, p-spine, l/s/ls...... .................. C................. ........... ........... ........... ........... ...........
22100.............. Remove part of neck .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
vertebra.
22101.............. Remove part, thorax .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
vertebra.
[[Page 67008]]
22102.............. Remove part, lumbar .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
vertebra.
22103.............. Remove extra spine segment .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
22110.............. Remove part of neck .................. C................. ........... ........... ........... ........... ...........
vertebra.
22112.............. Remove part, thorax .................. C................. ........... ........... ........... ........... ...........
vertebra.
22114.............. Remove part, lumbar .................. C................. ........... ........... ........... ........... ...........
vertebra.
22116.............. Remove extra spine segment .................. C................. ........... ........... ........... ........... ...........
22206.............. Cut spine 3 col, thor..... NI................ C................. ........... ........... ........... ........... ...........
22207.............. Cut spine 3 col, lumb..... NI................ C................. ........... ........... ........... ........... ...........
22208.............. Cut spine 3 col, addl seg. NI................ C................. ........... ........... ........... ........... ...........
22210.............. Revision of neck spine.... .................. C................. ........... ........... ........... ........... ...........
22212.............. Revision of thorax spine.. .................. C................. ........... ........... ........... ........... ...........
22214.............. Revision of lumbar spine.. .................. C................. ........... ........... ........... ........... ...........
22216.............. Revise, extra spine .................. C................. ........... ........... ........... ........... ...........
segment.
22220.............. Revision of neck spine.... .................. C................. ........... ........... ........... ........... ...........
22222.............. Revision of thorax spine.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
22224.............. Revision of lumbar spine.. .................. C................. ........... ........... ........... ........... ...........
22226.............. Revise, extra spine .................. C................. ........... ........... ........... ........... ...........
segment.
22305.............. Treat spine process .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
22310.............. Treat spine fracture...... .................. T................. 0043 1.7682 $112.62 ........... $22.52
22315.............. Treat spine fracture...... .................. T................. 0043 1.7682 $112.62 ........... $22.52
22318.............. Treat odontoid fx w/o .................. C................. ........... ........... ........... ........... ...........
graft.
22319.............. Treat odontoid fx w/graft. .................. C................. ........... ........... ........... ........... ...........
22325.............. Treat spine fracture...... .................. C................. ........... ........... ........... ........... ...........
22326.............. Treat neck spine fracture. .................. C................. ........... ........... ........... ........... ...........
22327.............. Treat thorax spine .................. C................. ........... ........... ........... ........... ...........
fracture.
22328.............. Treat each add spine fx... .................. C................. ........... ........... ........... ........... ...........
22505.............. Manipulation of spine..... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
22520.............. Percut vertebroplasty thor .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
22521.............. Percut vertebroplasty lumb .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
22522.............. Percut vertebroplasty .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
add'l.
22523.............. Percut kyphoplasty, thor.. .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
22524.............. Percut kyphoplasty, lumbar .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
22525.............. Percut kyphoplasty, add-on .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
22526.............. Idet, single level........ .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
22527.............. Idet, 1 or more levels.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
22532.............. Lat thorax spine fusion... .................. C................. ........... ........... ........... ........... ...........
22533.............. Lat lumbar spine fusion... .................. C................. ........... ........... ........... ........... ...........
22534.............. Lat thor/lumb, add'l seg.. .................. C................. ........... ........... ........... ........... ...........
22548.............. Neck spine fusion......... .................. C................. ........... ........... ........... ........... ...........
22554.............. Neck spine fusion......... .................. C................. ........... ........... ........... ........... ...........
22556.............. Thorax spine fusion....... .................. C................. ........... ........... ........... ........... ...........
22558.............. Lumbar spine fusion....... .................. C................. ........... ........... ........... ........... ...........
22585.............. Additional spinal fusion.. .................. C................. ........... ........... ........... ........... ...........
22590.............. Spine & skull spinal .................. C................. ........... ........... ........... ........... ...........
fusion.
22595.............. Neck spinal fusion........ .................. C................. ........... ........... ........... ........... ...........
22600.............. Neck spine fusion......... .................. C................. ........... ........... ........... ........... ...........
22610.............. Thorax spine fusion....... .................. C................. ........... ........... ........... ........... ...........
22612.............. Lumbar spine fusion....... .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
22614.............. Spine fusion, extra .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
segment.
22630.............. Lumbar spine fusion....... .................. C................. ........... ........... ........... ........... ...........
22632.............. Spine fusion, extra .................. C................. ........... ........... ........... ........... ...........
segment.
22800.............. Fusion of spine........... .................. C................. ........... ........... ........... ........... ...........
22802.............. Fusion of spine........... .................. C................. ........... ........... ........... ........... ...........
22804.............. Fusion of spine........... .................. C................. ........... ........... ........... ........... ...........
22808.............. Fusion of spine........... .................. C................. ........... ........... ........... ........... ...........
22810.............. Fusion of spine........... .................. C................. ........... ........... ........... ........... ...........
22812.............. Fusion of spine........... .................. C................. ........... ........... ........... ........... ...........
22818.............. Kyphectomy, 1-2 segments.. .................. C................. ........... ........... ........... ........... ...........
22819.............. Kyphectomy, 3 or more..... .................. C................. ........... ........... ........... ........... ...........
22830.............. Exploration of spinal .................. C................. ........... ........... ........... ........... ...........
fusion.
22840.............. Insert spine fixation .................. C................. ........... ........... ........... ........... ...........
device.
22841.............. Insert spine fixation .................. C................. ........... ........... ........... ........... ...........
device.
22842.............. Insert spine fixation .................. C................. ........... ........... ........... ........... ...........
device.
22843.............. Insert spine fixation .................. C................. ........... ........... ........... ........... ...........
device.
22844.............. Insert spine fixation .................. C................. ........... ........... ........... ........... ...........
device.
22845.............. Insert spine fixation .................. C................. ........... ........... ........... ........... ...........
device.
22846.............. Insert spine fixation .................. C................. ........... ........... ........... ........... ...........
device.
22847.............. Insert spine fixation .................. C................. ........... ........... ........... ........... ...........
device.
22848.............. Insert pelv fixation .................. C................. ........... ........... ........... ........... ...........
device.
22849.............. Reinsert spinal fixation.. .................. C................. ........... ........... ........... ........... ...........
22850.............. Remove spine fixation .................. C................. ........... ........... ........... ........... ...........
device.
22851.............. Apply spine prosth device. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
22852.............. Remove spine fixation .................. C................. ........... ........... ........... ........... ...........
device.
22855.............. Remove spine fixation .................. C................. ........... ........... ........... ........... ...........
device.
22857.............. Lumbar artif diskectomy... .................. C................. ........... ........... ........... ........... ...........
22862.............. Revise lumbar artif disc.. .................. C................. ........... ........... ........... ........... ...........
22865.............. Remove lumb artif disc.... .................. C................. ........... ........... ........... ........... ...........
22899.............. Spine surgery procedure... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
22900.............. Remove abdominal wall .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
lesion.
22999.............. Abdomen surgery procedure. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
[[Page 67009]]
23000.............. Removal of calcium .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
deposits.
23020.............. Release shoulder joint.... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
23030.............. Drain shoulder lesion..... .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
23031.............. Drain shoulder bursa...... .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
23035.............. Drain shoulder bone lesion .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
23040.............. Exploratory shoulder .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
surgery.
23044.............. Exploratory shoulder .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
surgery.
23065.............. Biopsy shoulder tissues... .................. T................. 0020 8.6850 $553.18 ........... $110.64
23066.............. Biopsy shoulder tissues... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
23075.............. Removal of shoulder lesion .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
23076.............. Removal of shoulder lesion .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
23077.............. Remove tumor of shoulder.. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
23100.............. Biopsy of shoulder joint.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
23101.............. Shoulder joint surgery.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23105.............. Remove shoulder joint .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lining.
23106.............. Incision of collarbone .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
joint.
23107.............. Explore treat shoulder .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
joint.
23120.............. Partial removal, collar CH................ T................. 0050 29.1900 $1,859.23 ........... $371.85
bone.
23125.............. Removal of collar bone.... CH................ T................. 0050 29.1900 $1,859.23 ........... $371.85
23130.............. Remove shoulder bone, part .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
23140.............. Removal of bone lesion.... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
23145.............. Removal of bone lesion.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23146.............. Removal of bone lesion.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23150.............. Removal of humerus lesion. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23155.............. Removal of humerus lesion. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23156.............. Removal of humerus lesion. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23170.............. Remove collar bone lesion. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23172.............. Remove shoulder blade .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lesion.
23174.............. Remove humerus lesion..... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23180.............. Remove collar bone lesion. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23182.............. Remove shoulder blade .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lesion.
23184.............. Remove humerus lesion..... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23190.............. Partial removal of scapula .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23195.............. Removal of head of humerus .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23200.............. Removal of collar bone.... .................. C................. ........... ........... ........... ........... ...........
23210.............. Removal of shoulder blade. .................. C................. ........... ........... ........... ........... ...........
23220.............. Partial removal of humerus .................. C................. ........... ........... ........... ........... ...........
23221.............. Partial removal of humerus .................. C................. ........... ........... ........... ........... ...........
23222.............. Partial removal of humerus .................. C................. ........... ........... ........... ........... ...........
23330.............. Remove shoulder foreign .................. T................. 0020 8.6850 $553.18 ........... $110.64
body.
23331.............. Remove shoulder foreign .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
body.
23332.............. Remove shoulder foreign .................. C................. ........... ........... ........... ........... ...........
body.
23350.............. Injection for shoulder x- .................. N................. ........... ........... ........... ........... ...........
ray.
23395.............. Muscle transfer,shoulder/ .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
arm.
23397.............. Muscle transfers.......... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
23400.............. Fixation of shoulder blade .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
23405.............. Incision of tendon & .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
muscle.
23406.............. Incise tendon(s) & .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
muscle(s).
23410.............. Repair rotator cuff, acute .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
23412.............. Repair rotator cuff, .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
chronic.
23415.............. Release of shoulder .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
ligament.
23420.............. Repair of shoulder........ .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
23430.............. Repair biceps tendon...... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
23440.............. Remove/transplant tendon.. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
23450.............. Repair shoulder capsule... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
23455.............. Repair shoulder capsule... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
23460.............. Repair shoulder capsule... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
23462.............. Repair shoulder capsule... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
23465.............. Repair shoulder capsule... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
23466.............. Repair shoulder capsule... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
23470.............. Reconstruct shoulder joint .................. T................. 0425 122.2057 $7,783.77 ........... $1,556.75
23472.............. Reconstruct shoulder joint .................. C................. ........... ........... ........... ........... ...........
23480.............. Revision of collar bone... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
23485.............. Revision of collar bone... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
23490.............. Reinforce clavicle........ .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
23491.............. Reinforce shoulder bones.. .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
23500.............. Treat clavicle fracture... .................. T................. 0043 1.7682 $112.62 ........... $22.52
23505.............. Treat clavicle fracture... .................. T................. 0043 1.7682 $112.62 ........... $22.52
23515.............. Treat clavicle fracture... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
23520.............. Treat clavicle dislocation .................. T................. 0043 1.7682 $112.62 ........... $22.52
23525.............. Treat clavicle dislocation .................. T................. 0043 1.7682 $112.62 ........... $22.52
23530.............. Treat clavicle dislocation .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
23532.............. Treat clavicle dislocation .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
23540.............. Treat clavicle dislocation .................. T................. 0043 1.7682 $112.62 ........... $22.52
23545.............. Treat clavicle dislocation .................. T................. 0043 1.7682 $112.62 ........... $22.52
23550.............. Treat clavicle dislocation .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
23552.............. Treat clavicle dislocation .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
23570.............. Treat shoulder blade fx... .................. T................. 0043 1.7682 $112.62 ........... $22.52
23575.............. Treat shoulder blade fx... .................. T................. 0043 1.7682 $112.62 ........... $22.52
23585.............. Treat scapula fracture.... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
[[Page 67010]]
23600.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
23605.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
23615.............. Treat humerus fracture.... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
23616.............. Treat humerus fracture.... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
23620.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
23625.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
23630.............. Treat humerus fracture.... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
23650.............. Treat shoulder dislocation .................. T................. 0043 1.7682 $112.62 ........... $22.52
23655.............. Treat shoulder dislocation .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
23660.............. Treat shoulder dislocation .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
23665.............. Treat dislocation/fracture .................. T................. 0043 1.7682 $112.62 ........... $22.52
23670.............. Treat dislocation/fracture .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
23675.............. Treat dislocation/fracture .................. T................. 0043 1.7682 $112.62 ........... $22.52
23680.............. Treat dislocation/fracture .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
23700.............. Fixation of shoulder...... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
23800.............. Fusion of shoulder joint.. .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
23802.............. Fusion of shoulder joint.. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
23900.............. Amputation of arm & girdle .................. C................. ........... ........... ........... ........... ...........
23920.............. Amputation at shoulder .................. C................. ........... ........... ........... ........... ...........
joint.
23921.............. Amputation follow-up CH................ T................. 0136 15.0458 $958.33 ........... $191.67
surgery.
23929.............. Shoulder surgery procedure .................. T................. 0043 1.7682 $112.62 ........... $22.52
23930.............. Drainage of arm lesion.... .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
23931.............. Drainage of arm bursa..... .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
23935.............. Drain arm/elbow bone .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
lesion.
24000.............. Exploratory elbow surgery. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24006.............. Release elbow joint....... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24065.............. Biopsy arm/elbow soft .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
tissue.
24066.............. Biopsy arm/elbow soft .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
tissue.
24075.............. Remove arm/elbow lesion... .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
24076.............. Remove arm/elbow lesion... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
24077.............. Remove tumor of arm/elbow. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
24100.............. Biopsy elbow joint lining. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
24101.............. Explore/treat elbow joint. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24102.............. Remove elbow joint lining. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24105.............. Removal of elbow bursa.... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
24110.............. Remove humerus lesion..... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
24115.............. Remove/graft bone lesion.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24116.............. Remove/graft bone lesion.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24120.............. Remove elbow lesion....... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
24125.............. Remove/graft bone lesion.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24126.............. Remove/graft bone lesion.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24130.............. Removal of head of radius. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24134.............. Removal of arm bone lesion .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24136.............. Remove radius bone lesion. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24138.............. Remove elbow bone lesion.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24140.............. Partial removal of arm .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
bone.
24145.............. Partial removal of radius. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24147.............. Partial removal of elbow.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24149.............. Radical resection of elbow .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24150.............. Extensive humerus surgery. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
24151.............. Extensive humerus surgery. .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
24152.............. Extensive radius surgery.. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
24153.............. Extensive radius surgery.. .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
24155.............. Removal of elbow joint.... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
24160.............. Remove elbow joint implant .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24164.............. Remove radius head implant .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24200.............. Removal of arm foreign .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
body.
24201.............. Removal of arm foreign .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
body.
24220.............. Injection for elbow x-ray. .................. N................. ........... ........... ........... ........... ...........
24300.............. Manipulate elbow w/anesth. .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
24301.............. Muscle/tendon transfer.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24305.............. Arm tendon lengthening.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24310.............. Revision of arm tendon.... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
24320.............. Repair of arm tendon...... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
24330.............. Revision of arm muscles... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
24331.............. Revision of arm muscles... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
24332.............. Tenolysis, triceps........ .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
24340.............. Repair of biceps tendon... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
24341.............. Repair arm tendon/muscle.. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
24342.............. Repair of ruptured tendon. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
24343.............. Repr elbow lat ligmnt w/ .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
tiss.
24344.............. Reconstruct elbow lat .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
ligmnt.
24345.............. Repr elbw med ligmnt w/ .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
tissu.
24346.............. Reconstruct elbow med .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
ligmnt.
24350.............. Repair of tennis elbow.... CH................ D................. ........... ........... ........... ........... ...........
24351.............. Repair of tennis elbow.... CH................ D................. ........... ........... ........... ........... ...........
24352.............. Repair of tennis elbow.... CH................ D................. ........... ........... ........... ........... ...........
24354.............. Repair of tennis elbow.... CH................ D................. ........... ........... ........... ........... ...........
24356.............. Revision of tennis elbow.. CH................ D................. ........... ........... ........... ........... ...........
24357.............. Repair elbow, perc........ NI................ T................. 0050 29.1900 $1,859.23 ........... $371.85
[[Page 67011]]
24358.............. Repair elbow w/deb, open.. NI................ T................. 0050 29.1900 $1,859.23 ........... $371.85
24359.............. Repair elbow deb/attch NI................ T................. 0050 29.1900 $1,859.23 ........... $371.85
open.
24360.............. Reconstruct elbow joint... .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
24361.............. Reconstruct elbow joint... .................. T................. 0425 122.2057 $7,783.77 ........... $1,556.75
24362.............. Reconstruct elbow joint... .................. T................. 0048 50.8876 $3,241.23 ........... $648.25
24363.............. Replace elbow joint....... .................. T................. 0425 122.2057 $7,783.77 ........... $1,556.75
24365.............. Reconstruct head of radius .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
24366.............. Reconstruct head of radius .................. T................. 0425 122.2057 $7,783.77 ........... $1,556.75
24400.............. Revision of humerus....... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24410.............. Revision of humerus....... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24420.............. Revision of humerus....... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
24430.............. Repair of humerus......... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
24435.............. Repair humerus with graft. .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
24470.............. Revision of elbow joint... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
24495.............. Decompression of forearm.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
24498.............. Reinforce humerus......... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
24500.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24505.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24515.............. Treat humerus fracture.... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
24516.............. Treat humerus fracture.... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
24530.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24535.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24538.............. Treat humerus fracture.... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
24545.............. Treat humerus fracture.... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
24546.............. Treat humerus fracture.... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
24560.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24565.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24566.............. Treat humerus fracture.... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
24575.............. Treat humerus fracture.... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
24576.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24577.............. Treat humerus fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24579.............. Treat humerus fracture.... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
24582.............. Treat humerus fracture.... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
24586.............. Treat elbow fracture...... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
24587.............. Treat elbow fracture...... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
24600.............. Treat elbow dislocation... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24605.............. Treat elbow dislocation... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
24615.............. Treat elbow dislocation... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
24620.............. Treat elbow fracture...... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24635.............. Treat elbow fracture...... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
24640.............. Treat elbow dislocation... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24650.............. Treat radius fracture..... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24655.............. Treat radius fracture..... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24665.............. Treat radius fracture..... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
24666.............. Treat radius fracture..... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
24670.............. Treat ulnar fracture...... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24675.............. Treat ulnar fracture...... .................. T................. 0043 1.7682 $112.62 ........... $22.52
24685.............. Treat ulnar fracture...... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
24800.............. Fusion of elbow joint..... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
24802.............. Fusion/graft of elbow .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
joint.
24900.............. Amputation of upper arm... .................. C................. ........... ........... ........... ........... ...........
24920.............. Amputation of upper arm... .................. C................. ........... ........... ........... ........... ...........
24925.............. Amputation follow-up .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
surgery.
24930.............. Amputation follow-up .................. C................. ........... ........... ........... ........... ...........
surgery.
24931.............. Amputate upper arm & .................. C................. ........... ........... ........... ........... ...........
implant.
24935.............. Revision of amputation.... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
24940.............. Revision of upper arm..... .................. C................. ........... ........... ........... ........... ...........
24999.............. Upper arm/elbow surgery... .................. T................. 0043 1.7682 $112.62 ........... $22.52
25000.............. Incision of tendon sheath. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
25001.............. Incise flexor carpi .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
radialis.
25020.............. Decompress forearm 1 space .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
25023.............. Decompress forearm 1 space .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25024.............. Decompress forearm 2 .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
spaces.
25025.............. Decompress forearm 2 .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
spaces.
25028.............. Drainage of forearm lesion .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
25031.............. Drainage of forearm bursa. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
25035.............. Treat forearm bone lesion. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
25040.............. Explore/treat wrist joint. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25065.............. Biopsy forearm soft .................. T................. 0020 8.6850 $553.18 ........... $110.64
tissues.
25066.............. Biopsy forearm soft .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
tissues.
25075.............. Removal forearm lesion .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
subcu.
25076.............. Removal forearm lesion .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
deep.
25077.............. Remove tumor, forearm/ .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
wrist.
25085.............. Incision of wrist capsule. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
25100.............. Biopsy of wrist joint..... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
25101.............. Explore/treat wrist joint. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25105.............. Remove wrist joint lining. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25107.............. Remove wrist joint .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
cartilage.
25109.............. Excise tendon forearm/ .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
wrist.
25110.............. Remove wrist tendon lesion .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
[[Page 67012]]
25111.............. Remove wrist tendon lesion .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
25112.............. Reremove wrist tendon .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
lesion.
25115.............. Remove wrist/forearm .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
lesion.
25116.............. Remove wrist/forearm .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
lesion.
25118.............. Excise wrist tendon sheath .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25119.............. Partial removal of ulna... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25120.............. Removal of forearm lesion. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25125.............. Remove/graft forearm .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lesion.
25126.............. Remove/graft forearm .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lesion.
25130.............. Removal of wrist lesion... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25135.............. Remove & graft wrist .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lesion.
25136.............. Remove & graft wrist .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lesion.
25145.............. Remove forearm bone lesion .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25150.............. Partial removal of ulna... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25151.............. Partial removal of radius. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25170.............. Extensive forearm surgery. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25210.............. Removal of wrist bone..... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
25215.............. Removal of wrist bones.... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
25230.............. Partial removal of radius. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25240.............. Partial removal of ulna... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25246.............. Injection for wrist x-ray. .................. N................. ........... ........... ........... ........... ...........
25248.............. Remove forearm foreign .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
body.
25250.............. Removal of wrist .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
prosthesis.
25251.............. Removal of wrist .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
prosthesis.
25259.............. Manipulate wrist w/ .................. T................. 0043 1.7682 $112.62 ........... $22.52
anesthes.
25260.............. Repair forearm tendon/ .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
muscle.
25263.............. Repair forearm tendon/ .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
muscle.
25265.............. Repair forearm tendon/ .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
muscle.
25270.............. Repair forearm tendon/ .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
muscle.
25272.............. Repair forearm tendon/ .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
muscle.
25274.............. Repair forearm tendon/ .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
muscle.
25275.............. Repair forearm tendon .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
sheath.
25280.............. Revise wrist/forearm .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
tendon.
25290.............. Incise wrist/forearm .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
tendon.
25295.............. Release wrist/forearm .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
tendon.
25300.............. Fusion of tendons at wrist .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25301.............. Fusion of tendons at wrist .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25310.............. Transplant forearm tendon. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25312.............. Transplant forearm tendon. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25315.............. Revise palsy hand .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
tendon(s).
25316.............. Revise palsy hand .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
tendon(s).
25320.............. Repair/revise wrist joint. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25332.............. Revise wrist joint........ .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
25335.............. Realignment of hand....... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25337.............. Reconstruct ulna/ .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
radioulnar.
25350.............. Revision of radius........ .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
25355.............. Revision of radius........ .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25360.............. Revision of ulna.......... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25365.............. Revise radius & ulna...... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25370.............. Revise radius or ulna..... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25375.............. Revise radius & ulna...... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25390.............. Shorten radius or ulna.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25391.............. Lengthen radius or ulna... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25392.............. Shorten radius & ulna..... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
25393.............. Lengthen radius & ulna.... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25394.............. Repair carpal bone, .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
shorten.
25400.............. Repair radius or ulna..... CH................ T................. 0052 79.4244 $5,058.86 ........... $1,011.77
25405.............. Repair/graft radius or CH................ T................. 0052 79.4244 $5,058.86 ........... $1,011.77
ulna.
25415.............. Repair radius & ulna...... CH................ T................. 0052 79.4244 $5,058.86 ........... $1,011.77
25420.............. Repair/graft radius & ulna .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
25425.............. Repair/graft radius or .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
ulna.
25426.............. Repair/graft radius & ulna .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25430.............. Vasc graft into carpal .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
bone.
25431.............. Repair nonunion carpal .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
bone.
25440.............. Repair/graft wrist bone... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
25441.............. Reconstruct wrist joint... .................. T................. 0425 122.2057 $7,783.77 ........... $1,556.75
25442.............. Reconstruct wrist joint... .................. T................. 0425 122.2057 $7,783.77 ........... $1,556.75
25443.............. Reconstruct wrist joint... .................. T................. 0048 50.8876 $3,241.23 ........... $648.25
25444.............. Reconstruct wrist joint... .................. T................. 0048 50.8876 $3,241.23 ........... $648.25
25445.............. Reconstruct wrist joint... .................. T................. 0048 50.8876 $3,241.23 ........... $648.25
25446.............. Wrist replacement......... .................. T................. 0425 122.2057 $7,783.77 ........... $1,556.75
25447.............. Repair wrist joint(s)..... .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
25449.............. Remove wrist joint implant .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
25450.............. Revision of wrist joint... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25455.............. Revision of wrist joint... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25490.............. Reinforce radius.......... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25491.............. Reinforce ulna............ .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25492.............. Reinforce radius and ulna. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
25500.............. Treat fracture of radius.. .................. T................. 0043 1.7682 $112.62 ........... $22.52
25505.............. Treat fracture of radius.. .................. T................. 0043 1.7682 $112.62 ........... $22.52
[[Page 67013]]
25515.............. Treat fracture of radius.. .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
25520.............. Treat fracture of radius.. .................. T................. 0043 1.7682 $112.62 ........... $22.52
25525.............. Treat fracture of radius.. .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
25526.............. Treat fracture of radius.. .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
25530.............. Treat fracture of ulna.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
25535.............. Treat fracture of ulna.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
25545.............. Treat fracture of ulna.... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
25560.............. Treat fracture radius & .................. T................. 0043 1.7682 $112.62 ........... $22.52
ulna.
25565.............. Treat fracture radius & .................. T................. 0043 1.7682 $112.62 ........... $22.52
ulna.
25574.............. Treat fracture radius & .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
ulna.
25575.............. Treat fracture radius/ulna .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
25600.............. Treat fracture radius/ulna .................. T................. 0043 1.7682 $112.62 ........... $22.52
25605.............. Treat fracture radius/ulna .................. T................. 0043 1.7682 $112.62 ........... $22.52
25606.............. Treat fx distal radial.... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
25607.............. Treat fx rad extra-articul .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
25608.............. Treat fx rad intra-articul .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
25609.............. Treat fx radial 3+ frag... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
25622.............. Treat wrist bone fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
25624.............. Treat wrist bone fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
25628.............. Treat wrist bone fracture. .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
25630.............. Treat wrist bone fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
25635.............. Treat wrist bone fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
25645.............. Treat wrist bone fracture. .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
25650.............. Treat wrist bone fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
25651.............. Pin ulnar styloid fracture .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
25652.............. Treat fracture ulnar .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
styloid.
25660.............. Treat wrist dislocation... .................. T................. 0043 1.7682 $112.62 ........... $22.52
25670.............. Treat wrist dislocation... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
25671.............. Pin radioulnar dislocation .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
25675.............. Treat wrist dislocation... .................. T................. 0043 1.7682 $112.62 ........... $22.52
25676.............. Treat wrist dislocation... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
25680.............. Treat wrist fracture...... .................. T................. 0043 1.7682 $112.62 ........... $22.52
25685.............. Treat wrist fracture...... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
25690.............. Treat wrist dislocation... .................. T................. 0043 1.7682 $112.62 ........... $22.52
25695.............. Treat wrist dislocation... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
25800.............. Fusion of wrist joint..... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
25805.............. Fusion/graft of wrist .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
joint.
25810.............. Fusion/graft of wrist .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
joint.
25820.............. Fusion of hand bones...... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
25825.............. Fuse hand bones with graft CH................ T................. 0052 79.4244 $5,058.86 ........... $1,011.77
25830.............. Fusion, radioulnar jnt/ .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
ulna.
25900.............. Amputation of forearm..... .................. C................. ........... ........... ........... ........... ...........
25905.............. Amputation of forearm..... .................. C................. ........... ........... ........... ........... ...........
25907.............. Amputation follow-up .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
surgery.
25909.............. Amputation follow-up .................. C................. ........... ........... ........... ........... ...........
surgery.
25915.............. Amputation of forearm..... .................. C................. ........... ........... ........... ........... ...........
25920.............. Amputate hand at wrist.... .................. C................. ........... ........... ........... ........... ...........
25922.............. Amputate hand at wrist.... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
25924.............. Amputation follow-up .................. C................. ........... ........... ........... ........... ...........
surgery.
25927.............. Amputation of hand........ .................. C................. ........... ........... ........... ........... ...........
25929.............. Amputation follow-up CH................ T................. 0136 15.0458 $958.33 ........... $191.67
surgery.
25931.............. Amputation follow-up CH................ T................. 0049 21.2689 $1,354.70 ........... $270.94
surgery.
25999.............. Forearm or wrist surgery.. .................. T................. 0043 1.7682 $112.62 ........... $22.52
26010.............. Drainage of finger abscess .................. T................. 0006 1.4066 $89.59 ........... $17.92
26011.............. Drainage of finger abscess .................. T................. 0007 11.5594 $736.26 ........... $147.25
26020.............. Drain hand tendon sheath.. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26025.............. Drainage of palm bursa.... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26030.............. Drainage of palm bursa(s). .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26034.............. Treat hand bone lesion.... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26035.............. Decompress fingers/hand... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26037.............. Decompress fingers/hand... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26040.............. Release palm contracture.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26045.............. Release palm contracture.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26055.............. Incise finger tendon .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
sheath.
26060.............. Incision of finger tendon. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26070.............. Explore/treat hand joint.. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26075.............. Explore/treat finger joint .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26080.............. Explore/treat finger joint .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26100.............. Biopsy hand joint lining.. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26105.............. Biopsy finger joint lining .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26110.............. Biopsy finger joint lining .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26115.............. Removal hand lesion subcut .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
26116.............. Removal hand lesion, deep. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
26117.............. Remove tumor, hand/finger. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
26121.............. Release palm contracture.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26123.............. Release palm contracture.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26125.............. Release palm contracture.. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26130.............. Remove wrist joint lining. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26135.............. Revise finger joint, each. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26140.............. Revise finger joint, each. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
[[Page 67014]]
26145.............. Tendon excision, palm/ .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
finger.
26160.............. Remove tendon sheath .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
lesion.
26170.............. Removal of palm tendon, .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
each.
26180.............. Removal of finger tendon.. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26185.............. Remove finger bone........ .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26200.............. Remove hand bone lesion... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26205.............. Remove/graft bone lesion.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26210.............. Removal of finger lesion.. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26215.............. Remove/graft finger lesion .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26230.............. Partial removal of hand .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
bone.
26235.............. Partial removal, finger .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
bone.
26236.............. Partial removal, finger .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
bone.
26250.............. Extensive hand surgery.... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26255.............. Extensive hand surgery.... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26260.............. Extensive finger surgery.. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26261.............. Extensive finger surgery.. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26262.............. Partial removal of finger. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26320.............. Removal of implant from .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
hand.
26340.............. Manipulate finger w/anesth .................. T................. 0043 1.7682 $112.62 ........... $22.52
26350.............. Repair finger/hand tendon. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26352.............. Repair/graft hand tendon.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26356.............. Repair finger/hand tendon. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26357.............. Repair finger/hand tendon. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26358.............. Repair/graft hand tendon.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26370.............. Repair finger/hand tendon. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26372.............. Repair/graft hand tendon.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26373.............. Repair finger/hand tendon. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26390.............. Revise hand/finger tendon. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26392.............. Repair/graft hand tendon.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26410.............. Repair hand tendon........ .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26412.............. Repair/graft hand tendon.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26415.............. Excision, hand/finger .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
tendon.
26416.............. Graft hand or finger .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
tendon.
26418.............. Repair finger tendon...... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26420.............. Repair/graft finger tendon .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26426.............. Repair finger/hand tendon. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26428.............. Repair/graft finger tendon .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26432.............. Repair finger tendon...... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26433.............. Repair finger tendon...... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26434.............. Repair/graft finger tendon .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26437.............. Realignment of tendons.... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26440.............. Release palm/finger tendon .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26442.............. Release palm & finger .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
tendon.
26445.............. Release hand/finger tendon .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26449.............. Release forearm/hand .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
tendon.
26450.............. Incision of palm tendon... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26455.............. Incision of finger tendon. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26460.............. Incise hand/finger tendon. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26471.............. Fusion of finger tendons.. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26474.............. Fusion of finger tendons.. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26476.............. Tendon lengthening........ .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26477.............. Tendon shortening......... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26478.............. Lengthening of hand tendon .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26479.............. Shortening of hand tendon. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26480.............. Transplant hand tendon.... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26483.............. Transplant/graft hand .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
tendon.
26485.............. Transplant palm tendon.... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26489.............. Transplant/graft palm .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
tendon.
26490.............. Revise thumb tendon....... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26492.............. Tendon transfer with graft .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26494.............. Hand tendon/muscle .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
transfer.
26496.............. Revise thumb tendon....... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26497.............. Finger tendon transfer.... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26498.............. Finger tendon transfer.... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26499.............. Revision of finger........ .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26500.............. Hand tendon reconstruction .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26502.............. Hand tendon reconstruction .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26508.............. Release thumb contracture. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26510.............. Thumb tendon transfer..... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26516.............. Fusion of knuckle joint... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26517.............. Fusion of knuckle joints.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26518.............. Fusion of knuckle joints.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26520.............. Release knuckle .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
contracture.
26525.............. Release finger contracture .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26530.............. Revise knuckle joint...... .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
26531.............. Revise knuckle with .................. T................. 0048 50.8876 $3,241.23 ........... $648.25
implant.
26535.............. Revise finger joint....... .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
26536.............. Revise/implant finger .................. T................. 0048 50.8876 $3,241.23 ........... $648.25
joint.
26540.............. Repair hand joint......... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26541.............. Repair hand joint with .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
graft.
[[Page 67015]]
26542.............. Repair hand joint with .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
graft.
26545.............. Reconstruct finger joint.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26546.............. Repair nonunion hand...... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26548.............. Reconstruct finger joint.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26550.............. Construct thumb .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
replacement.
26551.............. Great toe-hand transfer... .................. C................. ........... ........... ........... ........... ...........
26553.............. Single transfer, toe-hand. .................. C................. ........... ........... ........... ........... ...........
26554.............. Double transfer, toe-hand. .................. C................. ........... ........... ........... ........... ...........
26555.............. Positional change of .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
finger.
26556.............. Toe joint transfer........ .................. C................. ........... ........... ........... ........... ...........
26560.............. Repair of web finger...... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26561.............. Repair of web finger...... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26562.............. Repair of web finger...... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26565.............. Correct metacarpal flaw... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26567.............. Correct finger deformity.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26568.............. Lengthen metacarpal/finger .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26580.............. Repair hand deformity..... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26587.............. Reconstruct extra finger.. .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26590.............. Repair finger deformity... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26591.............. Repair muscles of hand.... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26593.............. Release muscles of hand... .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26596.............. Excision constricting .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
tissue.
26600.............. Treat metacarpal fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
26605.............. Treat metacarpal fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
26607.............. Treat metacarpal fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
26608.............. Treat metacarpal fracture. .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
26615.............. Treat metacarpal fracture. .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
26641.............. Treat thumb dislocation... .................. T................. 0043 1.7682 $112.62 ........... $22.52
26645.............. Treat thumb fracture...... .................. T................. 0043 1.7682 $112.62 ........... $22.52
26650.............. Treat thumb fracture...... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
26665.............. Treat thumb fracture...... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
26670.............. Treat hand dislocation.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
26675.............. Treat hand dislocation.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
26676.............. Pin hand dislocation...... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
26685.............. Treat hand dislocation.... CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
26686.............. Treat hand dislocation.... .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
26700.............. Treat knuckle dislocation. .................. T................. 0043 1.7682 $112.62 ........... $22.52
26705.............. Treat knuckle dislocation. .................. T................. 0043 1.7682 $112.62 ........... $22.52
26706.............. Pin knuckle dislocation... .................. T................. 0043 1.7682 $112.62 ........... $22.52
26715.............. Treat knuckle dislocation. CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
26720.............. Treat finger fracture, .................. T................. 0043 1.7682 $112.62 ........... $22.52
each.
26725.............. Treat finger fracture, .................. T................. 0043 1.7682 $112.62 ........... $22.52
each.
26727.............. Treat finger fracture, .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
each.
26735.............. Treat finger fracture, CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
each.
26740.............. Treat finger fracture, .................. T................. 0043 1.7682 $112.62 ........... $22.52
each.
26742.............. Treat finger fracture, .................. T................. 0043 1.7682 $112.62 ........... $22.52
each.
26746.............. Treat finger fracture, CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
each.
26750.............. Treat finger fracture, .................. T................. 0043 1.7682 $112.62 ........... $22.52
each.
26755.............. Treat finger fracture, .................. T................. 0043 1.7682 $112.62 ........... $22.52
each.
26756.............. Pin finger fracture, each. .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
26765.............. Treat finger fracture, CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
each.
26770.............. Treat finger dislocation.. .................. T................. 0043 1.7682 $112.62 ........... $22.52
26775.............. Treat finger dislocation.. .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
26776.............. Pin finger dislocation.... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
26785.............. Treat finger dislocation.. .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
26820.............. Thumb fusion with graft... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26841.............. Fusion of thumb........... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26842.............. Thumb fusion with graft... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26843.............. Fusion of hand joint...... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26844.............. Fusion/graft of hand joint .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26850.............. Fusion of knuckle......... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26852.............. Fusion of knuckle with .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
graft.
26860.............. Fusion of finger joint.... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26861.............. Fusion of finger jnt, add- .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
on.
26862.............. Fusion/graft of finger .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
joint.
26863.............. Fuse/graft added joint.... .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26910.............. Amputate metacarpal bone.. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
26951.............. Amputation of finger/thumb .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26952.............. Amputation of finger/thumb .................. T................. 0053 16.4637 $1,048.64 $253.49 $209.73
26989.............. Hand/finger surgery....... .................. T................. 0043 1.7682 $112.62 ........... $22.52
26990.............. Drainage of pelvis lesion. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
26991.............. Drainage of pelvis bursa.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
26992.............. Drainage of bone lesion... .................. C................. ........... ........... ........... ........... ...........
27000.............. Incision of hip tendon.... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27001.............. Incision of hip tendon.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27003.............. Incision of hip tendon.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27005.............. Incision of hip tendon.... .................. C................. ........... ........... ........... ........... ...........
27006.............. Incision of hip tendons... CH................ T................. 0050 29.1900 $1,859.23 ........... $371.85
27025.............. Incision of hip/thigh .................. C................. ........... ........... ........... ........... ...........
fascia.
27030.............. Drainage of hip joint..... .................. C................. ........... ........... ........... ........... ...........
[[Page 67016]]
27033.............. Exploration of hip joint.. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27035.............. Denervation of hip joint.. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27036.............. Excision of hip joint/ .................. C................. ........... ........... ........... ........... ...........
muscle.
27040.............. Biopsy of soft tissues.... .................. T................. 0020 8.6850 $553.18 ........... $110.64
27041.............. Biopsy of soft tissues.... .................. T................. 0020 8.6850 $553.18 ........... $110.64
27047.............. Remove hip/pelvis lesion.. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
27048.............. Remove hip/pelvis lesion.. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
27049.............. Remove tumor, hip/pelvis.. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
27050.............. Biopsy of sacroiliac joint .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27052.............. Biopsy of hip joint....... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27054.............. Removal of hip joint .................. C................. ........... ........... ........... ........... ...........
lining.
27060.............. Removal of ischial bursa.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27062.............. Remove femur lesion/bursa. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27065.............. Removal of hip bone lesion .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27066.............. Removal of hip bone lesion .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27067.............. Remove/graft hip bone .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lesion.
27070.............. Partial removal of hip .................. C................. ........... ........... ........... ........... ...........
bone.
27071.............. Partial removal of hip .................. C................. ........... ........... ........... ........... ...........
bone.
27075.............. Extensive hip surgery..... .................. C................. ........... ........... ........... ........... ...........
27076.............. Extensive hip surgery..... .................. C................. ........... ........... ........... ........... ...........
27077.............. Extensive hip surgery..... .................. C................. ........... ........... ........... ........... ...........
27078.............. Extensive hip surgery..... .................. C................. ........... ........... ........... ........... ...........
27079.............. Extensive hip surgery..... .................. C................. ........... ........... ........... ........... ...........
27080.............. Removal of tail bone...... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27086.............. Remove hip foreign body... .................. T................. 0020 8.6850 $553.18 ........... $110.64
27087.............. Remove hip foreign body... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27090.............. Removal of hip prosthesis. .................. C................. ........... ........... ........... ........... ...........
27091.............. Removal of hip prosthesis. .................. C................. ........... ........... ........... ........... ...........
27093.............. Injection for hip x-ray... .................. N................. ........... ........... ........... ........... ...........
27095.............. Injection for hip x-ray... .................. N................. ........... ........... ........... ........... ...........
27096.............. Inject sacroiliac joint... .................. B................. ........... ........... ........... ........... ...........
27097.............. Revision of hip tendon.... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27098.............. Transfer tendon to pelvis. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27100.............. Transfer of abdominal .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
muscle.
27105.............. Transfer of spinal muscle. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27110.............. Transfer of iliopsoas .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
muscle.
27111.............. Transfer of iliopsoas .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
muscle.
27120.............. Reconstruction of hip .................. C................. ........... ........... ........... ........... ...........
socket.
27122.............. Reconstruction of hip .................. C................. ........... ........... ........... ........... ...........
socket.
27125.............. Partial hip replacement... .................. C................. ........... ........... ........... ........... ...........
27130.............. Total hip arthroplasty.... .................. C................. ........... ........... ........... ........... ...........
27132.............. Total hip arthroplasty.... .................. C................. ........... ........... ........... ........... ...........
27134.............. Revise hip joint .................. C................. ........... ........... ........... ........... ...........
replacement.
27137.............. Revise hip joint .................. C................. ........... ........... ........... ........... ...........
replacement.
27138.............. Revise hip joint .................. C................. ........... ........... ........... ........... ...........
replacement.
27140.............. Transplant femur ridge.... .................. C................. ........... ........... ........... ........... ...........
27146.............. Incision of hip bone...... .................. C................. ........... ........... ........... ........... ...........
27147.............. Revision of hip bone...... .................. C................. ........... ........... ........... ........... ...........
27151.............. Incision of hip bones..... .................. C................. ........... ........... ........... ........... ...........
27156.............. Revision of hip bones..... .................. C................. ........... ........... ........... ........... ...........
27158.............. Revision of pelvis........ .................. C................. ........... ........... ........... ........... ...........
27161.............. Incision of neck of femur. .................. C................. ........... ........... ........... ........... ...........
27165.............. Incision/fixation of femur .................. C................. ........... ........... ........... ........... ...........
27170.............. Repair/graft femur head/ .................. C................. ........... ........... ........... ........... ...........
neck.
27175.............. Treat slipped epiphysis... .................. C................. ........... ........... ........... ........... ...........
27176.............. Treat slipped epiphysis... .................. C................. ........... ........... ........... ........... ...........
27177.............. Treat slipped epiphysis... .................. C................. ........... ........... ........... ........... ...........
27178.............. Treat slipped epiphysis... .................. C................. ........... ........... ........... ........... ...........
27179.............. Revise head/neck of femur. .................. C................. ........... ........... ........... ........... ...........
27181.............. Treat slipped epiphysis... .................. C................. ........... ........... ........... ........... ...........
27185.............. Revision of femur .................. C................. ........... ........... ........... ........... ...........
epiphysis.
27187.............. Reinforce hip bones....... .................. C................. ........... ........... ........... ........... ...........
27193.............. Treat pelvic ring fracture .................. T................. 0043 1.7682 $112.62 ........... $22.52
27194.............. Treat pelvic ring fracture .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
27200.............. Treat tail bone fracture.. .................. T................. 0043 1.7682 $112.62 ........... $22.52
27202.............. Treat tail bone fracture.. .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
27215.............. Treat pelvic fracture(s).. .................. C................. ........... ........... ........... ........... ...........
27216.............. Treat pelvic ring fracture .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27217.............. Treat pelvic ring fracture .................. C................. ........... ........... ........... ........... ...........
27218.............. Treat pelvic ring fracture .................. C................. ........... ........... ........... ........... ...........
27220.............. Treat hip socket fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
27222.............. Treat hip socket fracture. .................. C................. ........... ........... ........... ........... ...........
27226.............. Treat hip wall fracture... .................. C................. ........... ........... ........... ........... ...........
27227.............. Treat hip fracture(s)..... .................. C................. ........... ........... ........... ........... ...........
27228.............. Treat hip fracture(s)..... .................. C................. ........... ........... ........... ........... ...........
27230.............. Treat thigh fracture...... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27232.............. Treat thigh fracture...... .................. C................. ........... ........... ........... ........... ...........
27235.............. Treat thigh fracture...... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27236.............. Treat thigh fracture...... .................. C................. ........... ........... ........... ........... ...........
27238.............. Treat thigh fracture...... .................. T................. 0043 1.7682 $112.62 ........... $22.52
[[Page 67017]]
27240.............. Treat thigh fracture...... .................. C................. ........... ........... ........... ........... ...........
27244.............. Treat thigh fracture...... .................. C................. ........... ........... ........... ........... ...........
27245.............. Treat thigh fracture...... .................. C................. ........... ........... ........... ........... ...........
27246.............. Treat thigh fracture...... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27248.............. Treat thigh fracture...... .................. C................. ........... ........... ........... ........... ...........
27250.............. Treat hip dislocation..... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27252.............. Treat hip dislocation..... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
27253.............. Treat hip dislocation..... .................. C................. ........... ........... ........... ........... ...........
27254.............. Treat hip dislocation..... .................. C................. ........... ........... ........... ........... ...........
27256.............. Treat hip dislocation..... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27257.............. Treat hip dislocation..... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
27258.............. Treat hip dislocation..... .................. C................. ........... ........... ........... ........... ...........
27259.............. Treat hip dislocation..... .................. C................. ........... ........... ........... ........... ...........
27265.............. Treat hip dislocation..... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27266.............. Treat hip dislocation..... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
27267.............. Cltx thigh fx............. NI................ T................. 0043 1.7682 $112.62 ........... $22.52
27268.............. Cltx thigh fx w/mnpj...... NI................ C................. ........... ........... ........... ........... ...........
27269.............. Optx thigh fx............. NI................ C................. ........... ........... ........... ........... ...........
27275.............. Manipulation of hip joint. .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
27280.............. Fusion of sacroiliac joint .................. C................. ........... ........... ........... ........... ...........
27282.............. Fusion of pubic bones..... .................. C................. ........... ........... ........... ........... ...........
27284.............. Fusion of hip joint....... .................. C................. ........... ........... ........... ........... ...........
27286.............. Fusion of hip joint....... .................. C................. ........... ........... ........... ........... ...........
27290.............. Amputation of leg at hip.. .................. C................. ........... ........... ........... ........... ...........
27295.............. Amputation of leg at hip.. .................. C................. ........... ........... ........... ........... ...........
27299.............. Pelvis/hip joint surgery.. .................. T................. 0043 1.7682 $112.62 ........... $22.52
27301.............. Drain thigh/knee lesion... .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
27303.............. Drainage of bone lesion... .................. C................. ........... ........... ........... ........... ...........
27305.............. Incise thigh tendon & .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
fascia.
27306.............. Incision of thigh tendon.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27307.............. Incision of thigh tendons. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27310.............. Exploration of knee joint. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27323.............. Biopsy, thigh soft tissues .................. T................. 0020 8.6850 $553.18 ........... $110.64
27324.............. Biopsy, thigh soft tissues .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
27325.............. Neurectomy, hamstring..... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
27326.............. Neurectomy, popliteal..... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
27327.............. Removal of thigh lesion... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
27328.............. Removal of thigh lesion... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
27329.............. Remove tumor, thigh/knee.. .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
27330.............. Biopsy, knee joint lining. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27331.............. Explore/treat knee joint.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27332.............. Removal of knee cartilage. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27333.............. Removal of knee cartilage. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27334.............. Remove knee joint lining.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27335.............. Remove knee joint lining.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27340.............. Removal of kneecap bursa.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27345.............. Removal of knee cyst...... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27347.............. Remove knee cyst.......... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27350.............. Removal of kneecap........ .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27355.............. Remove femur lesion....... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27356.............. Remove femur lesion/graft. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27357.............. Remove femur lesion/graft. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27358.............. Remove femur lesion/ .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
fixation.
27360.............. Partial removal, leg .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
bone(s).
27365.............. Extensive leg surgery..... .................. C................. ........... ........... ........... ........... ...........
27370.............. Injection for knee x-ray.. .................. N................. ........... ........... ........... ........... ...........
27372.............. Removal of foreign body... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
27380.............. Repair of kneecap tendon.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27381.............. Repair/graft kneecap .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
tendon.
27385.............. Repair of thigh muscle.... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27386.............. Repair/graft of thigh .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
muscle.
27390.............. Incision of thigh tendon.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27391.............. Incision of thigh tendons. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27392.............. Incision of thigh tendons. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27393.............. Lengthening of thigh .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
tendon.
27394.............. Lengthening of thigh .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
tendons.
27395.............. Lengthening of thigh .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
tendons.
27396.............. Transplant of thigh tendon .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27397.............. Transplants of thigh .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
tendons.
27400.............. Revise thigh muscles/ .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
tendons.
27403.............. Repair of knee cartilage.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27405.............. Repair of knee ligament... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27407.............. Repair of knee ligament... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
27409.............. Repair of knee ligaments.. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27412.............. Autochondrocyte implant .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
knee.
27415.............. Osteochondral knee .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
allograft.
27416.............. Osteochondral knee NI................ T................. 0051 42.9850 $2,737.89 ........... $547.58
autograft.
27418.............. Repair degenerated kneecap .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27420.............. Revision of unstable .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
kneecap.
27422.............. Revision of unstable .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
kneecap.
[[Page 67018]]
27424.............. Revision/removal of .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
kneecap.
27425.............. Lat retinacular release .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
open.
27427.............. Reconstruction, knee...... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27428.............. Reconstruction, knee...... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
27429.............. Reconstruction, knee...... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
27430.............. Revision of thigh muscles. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27435.............. Incision of knee joint.... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27437.............. Revise kneecap............ .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
27438.............. Revise kneecap with .................. T................. 0048 50.8876 $3,241.23 ........... $648.25
implant.
27440.............. Revision of knee joint.... .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
27441.............. Revision of knee joint.... .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
27442.............. Revision of knee joint.... .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
27443.............. Revision of knee joint.... .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
27445.............. Revision of knee joint.... .................. C................. ........... ........... ........... ........... ...........
27446.............. Revision of knee joint.... .................. T................. 0681 274.6715 $17,494.93 ........... $3,498.99
27447.............. Total knee arthroplasty... .................. C................. ........... ........... ........... ........... ...........
27448.............. Incision of thigh......... .................. C................. ........... ........... ........... ........... ...........
27450.............. Incision of thigh......... .................. C................. ........... ........... ........... ........... ...........
27454.............. Realignment of thigh bone. .................. C................. ........... ........... ........... ........... ...........
27455.............. Realignment of knee....... .................. C................. ........... ........... ........... ........... ...........
27457.............. Realignment of knee....... .................. C................. ........... ........... ........... ........... ...........
27465.............. Shortening of thigh bone.. .................. C................. ........... ........... ........... ........... ...........
27466.............. Lengthening of thigh bone. .................. C................. ........... ........... ........... ........... ...........
27468.............. Shorten/lengthen thighs... .................. C................. ........... ........... ........... ........... ...........
27470.............. Repair of thigh........... .................. C................. ........... ........... ........... ........... ...........
27472.............. Repair/graft of thigh..... .................. C................. ........... ........... ........... ........... ...........
27475.............. Surgery to stop leg growth .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27477.............. Surgery to stop leg growth .................. C................. ........... ........... ........... ........... ...........
27479.............. Surgery to stop leg growth .................. C................. ........... ........... ........... ........... ...........
27485.............. Surgery to stop leg growth .................. C................. ........... ........... ........... ........... ...........
27486.............. Revise/replace knee joint. .................. C................. ........... ........... ........... ........... ...........
27487.............. Revise/replace knee joint. .................. C................. ........... ........... ........... ........... ...........
27488.............. Removal of knee prosthesis .................. C................. ........... ........... ........... ........... ...........
27495.............. Reinforce thigh........... .................. C................. ........... ........... ........... ........... ...........
27496.............. Decompression of thigh/ .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
knee.
27497.............. Decompression of thigh/ .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
knee.
27498.............. Decompression of thigh/ .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
knee.
27499.............. Decompression of thigh/ .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
knee.
27500.............. Treatment of thigh .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27501.............. Treatment of thigh .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27502.............. Treatment of thigh .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27503.............. Treatment of thigh .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27506.............. Treatment of thigh .................. C................. ........... ........... ........... ........... ...........
fracture.
27507.............. Treatment of thigh .................. C................. ........... ........... ........... ........... ...........
fracture.
27508.............. Treatment of thigh .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27509.............. Treatment of thigh .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
fracture.
27510.............. Treatment of thigh .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27511.............. Treatment of thigh .................. C................. ........... ........... ........... ........... ...........
fracture.
27513.............. Treatment of thigh .................. C................. ........... ........... ........... ........... ...........
fracture.
27514.............. Treatment of thigh .................. C................. ........... ........... ........... ........... ...........
fracture.
27516.............. Treat thigh fx growth .................. T................. 0043 1.7682 $112.62 ........... $22.52
plate.
27517.............. Treat thigh fx growth .................. T................. 0043 1.7682 $112.62 ........... $22.52
plate.
27519.............. Treat thigh fx growth .................. C................. ........... ........... ........... ........... ...........
plate.
27520.............. Treat kneecap fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27524.............. Treat kneecap fracture.... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
27530.............. Treat knee fracture....... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27532.............. Treat knee fracture....... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27535.............. Treat knee fracture....... .................. C................. ........... ........... ........... ........... ...........
27536.............. Treat knee fracture....... .................. C................. ........... ........... ........... ........... ...........
27538.............. Treat knee fracture(s).... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27540.............. Treat knee fracture....... .................. C................. ........... ........... ........... ........... ...........
27550.............. Treat knee dislocation.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27552.............. Treat knee dislocation.... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
27556.............. Treat knee dislocation.... .................. C................. ........... ........... ........... ........... ...........
27557.............. Treat knee dislocation.... .................. C................. ........... ........... ........... ........... ...........
27558.............. Treat knee dislocation.... .................. C................. ........... ........... ........... ........... ...........
27560.............. Treat kneecap dislocation. .................. T................. 0043 1.7682 $112.62 ........... $22.52
27562.............. Treat kneecap dislocation. .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
27566.............. Treat kneecap dislocation. .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
27570.............. Fixation of knee joint.... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
27580.............. Fusion of knee............ .................. C................. ........... ........... ........... ........... ...........
27590.............. Amputate leg at thigh..... .................. C................. ........... ........... ........... ........... ...........
27591.............. Amputate leg at thigh..... .................. C................. ........... ........... ........... ........... ...........
27592.............. Amputate leg at thigh..... .................. C................. ........... ........... ........... ........... ...........
27594.............. Amputation follow-up .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
surgery.
27596.............. Amputation follow-up .................. C................. ........... ........... ........... ........... ...........
surgery.
27598.............. Amputate lower leg at knee .................. C................. ........... ........... ........... ........... ...........
27599.............. Leg surgery procedure..... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27600.............. Decompression of lower leg .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27601.............. Decompression of lower leg .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
[[Page 67019]]
27602.............. Decompression of lower leg .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27603.............. Drain lower leg lesion.... .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
27604.............. Drain lower leg bursa..... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27605.............. Incision of achilles .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
tendon.
27606.............. Incision of achilles .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
tendon.
27607.............. Treat lower leg bone .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
lesion.
27610.............. Explore/treat ankle joint. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27612.............. Exploration of ankle joint .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27613.............. Biopsy lower leg soft .................. T................. 0020 8.6850 $553.18 ........... $110.64
tissue.
27614.............. Biopsy lower leg soft .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
tissue.
27615.............. Remove tumor, lower leg... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27618.............. Remove lower leg lesion... .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
27619.............. Remove lower leg lesion... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
27620.............. Explore/treat ankle joint. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27625.............. Remove ankle joint lining. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27626.............. Remove ankle joint lining. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27630.............. Removal of tendon lesion.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27635.............. Remove lower leg bone .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lesion.
27637.............. Remove/graft leg bone .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lesion.
27638.............. Remove/graft leg bone .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
lesion.
27640.............. Partial removal of tibia.. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27641.............. Partial removal of fibula. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27645.............. Extensive lower leg .................. C................. ........... ........... ........... ........... ...........
surgery.
27646.............. Extensive lower leg .................. C................. ........... ........... ........... ........... ...........
surgery.
27647.............. Extensive ankle/heel .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
surgery.
27648.............. Injection for ankle x-ray. .................. N................. ........... ........... ........... ........... ...........
27650.............. Repair achilles tendon.... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27652.............. Repair/graft achilles .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
tendon.
27654.............. Repair of achilles tendon. .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27656.............. Repair leg fascia defect.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27658.............. Repair of leg tendon, each .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27659.............. Repair of leg tendon, each .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27664.............. Repair of leg tendon, each .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27665.............. Repair of leg tendon, each .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27675.............. Repair lower leg tendons.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27676.............. Repair lower leg tendons.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27680.............. Release of lower leg .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
tendon.
27681.............. Release of lower leg .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
tendons.
27685.............. Revision of lower leg .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
tendon.
27686.............. Revise lower leg tendons.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27687.............. Revision of calf tendon... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27690.............. Revise lower leg tendon... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27691.............. Revise lower leg tendon... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27692.............. Revise additional leg .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
tendon.
27695.............. Repair of ankle ligament.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27696.............. Repair of ankle ligaments. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27698.............. Repair of ankle ligament.. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27700.............. Revision of ankle joint... .................. T................. 0047 35.9040 $2,286.87 $537.03 $457.37
27702.............. Reconstruct ankle joint... .................. C................. ........... ........... ........... ........... ...........
27703.............. Reconstruction, ankle .................. C................. ........... ........... ........... ........... ...........
joint.
27704.............. Removal of ankle implant.. .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27705.............. Incision of tibia......... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27707.............. Incision of fibula........ .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27709.............. Incision of tibia & fibula .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27712.............. Realignment of lower leg.. .................. C................. ........... ........... ........... ........... ...........
27715.............. Revision of lower leg..... .................. C................. ........... ........... ........... ........... ...........
27720.............. Repair of tibia........... CH................ T................. 0063 41.1091 $2,618.40 $548.33 $523.68
27722.............. Repair/graft of tibia..... CH................ T................. 0064 59.2233 $3,772.17 $835.79 $754.43
27724.............. Repair/graft of tibia..... .................. C................. ........... ........... ........... ........... ...........
27725.............. Repair of lower leg....... .................. C................. ........... ........... ........... ........... ...........
27726.............. Repair fibula nonunion.... NI................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
27727.............. Repair of lower leg....... .................. C................. ........... ........... ........... ........... ...........
27730.............. Repair of tibia epiphysis. .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27732.............. Repair of fibula epiphysis .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27734.............. Repair lower leg epiphyses .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27740.............. Repair of leg epiphyses... .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
27742.............. Repair of leg epiphyses... .................. T................. 0051 42.9850 $2,737.89 ........... $547.58
27745.............. Reinforce tibia........... .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
27750.............. Treatment of tibia .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27752.............. Treatment of tibia .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27756.............. Treatment of tibia .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
fracture.
27758.............. Treatment of tibia .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
fracture.
27759.............. Treatment of tibia .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
fracture.
27760.............. Cltx medial ankle fx...... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27762.............. Cltx med ankle fx w/mnpj.. .................. T................. 0043 1.7682 $112.62 ........... $22.52
27766.............. Optx medial ankle fx...... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
27767.............. Cltx post ankle fx........ NI................ T................. 0043 1.7682 $112.62 ........... $22.52
27768.............. Cltx post ankle fx w/mnpj. NI................ T................. 0043 1.7682 $112.62 ........... $22.52
27769.............. Optx post ankle fx........ NI................ T................. 0063 41.1091 $2,618.40 $548.33 $523.68
27780.............. Treatment of fibula .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
[[Page 67020]]
27781.............. Treatment of fibula .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27784.............. Treatment of fibula .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
fracture.
27786.............. Treatment of ankle .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27788.............. Treatment of ankle .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27792.............. Treatment of ankle .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
fracture.
27808.............. Treatment of ankle .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27810.............. Treatment of ankle .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27814.............. Treatment of ankle .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
fracture.
27816.............. Treatment of ankle .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27818.............. Treatment of ankle .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
27822.............. Treatment of ankle .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
fracture.
27823.............. Treatment of ankle .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
fracture.
27824.............. Treat lower leg fracture.. .................. T................. 0043 1.7682 $112.62 ........... $22.52
27825.............. Treat lower leg fracture.. .................. T................. 0043 1.7682 $112.62 ........... $22.52
27826.............. Treat lower leg fracture.. .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
27827.............. Treat lower leg fracture.. .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
27828.............. Treat lower leg fracture.. .................. T................. 0064 59.2233 $3,772.17 $835.79 $754.43
27829.............. Treat lower leg joint..... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
27830.............. Treat lower leg .................. T................. 0043 1.7682 $112.62 ........... $22.52
dislocation.
27831.............. Treat lower leg .................. T................. 0043 1.7682 $112.62 ........... $22.52
dislocation.
27832.............. Treat lower leg .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
dislocation.
27840.............. Treat ankle dislocation... .................. T................. 0043 1.7682 $112.62 ........... $22.52
27842.............. Treat ankle dislocation... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
27846.............. Treat ankle dislocation... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
27848.............. Treat ankle dislocation... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
27860.............. Fixation of ankle joint... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
27870.............. Fusion of ankle joint, .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
open.
27871.............. Fusion of tibiofibular .................. T................. 0052 79.4244 $5,058.86 ........... $1,011.77
joint.
27880.............. Amputation of lower leg... .................. C................. ........... ........... ........... ........... ...........
27881.............. Amputation of lower leg... .................. C................. ........... ........... ........... ........... ...........
27882.............. Amputation of lower leg... .................. C................. ........... ........... ........... ........... ...........
27884.............. Amputation follow-up .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
surgery.
27886.............. Amputation follow-up .................. C................. ........... ........... ........... ........... ...........
surgery.
27888.............. Amputation of foot at .................. C................. ........... ........... ........... ........... ...........
ankle.
27889.............. Amputation of foot at .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
ankle.
27892.............. Decompression of leg...... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27893.............. Decompression of leg...... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27894.............. Decompression of leg...... .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
27899.............. Leg/ankle surgery .................. T................. 0043 1.7682 $112.62 ........... $22.52
procedure.
28001.............. Drainage of bursa of foot. .................. T................. 0007 11.5594 $736.26 ........... $147.25
28002.............. Treatment of foot .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
infection.
28003.............. Treatment of foot .................. T................. 0049 21.2689 $1,354.70 ........... $270.94
infection.
28005.............. Treat foot bone lesion.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28008.............. Incision of foot fascia... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28010.............. Incision of toe tendon.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28011.............. Incision of toe tendons... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28020.............. Exploration of foot joint. .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28022.............. Exploration of foot joint. .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28024.............. Exploration of toe joint.. .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28035.............. Decompression of tibia .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
nerve.
28043.............. Excision of foot lesion... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
28045.............. Excision of foot lesion... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28046.............. Resection of tumor, foot.. .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28050.............. Biopsy of foot joint .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
lining.
28052.............. Biopsy of foot joint .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
lining.
28054.............. Biopsy of toe joint lining .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28055.............. Neurectomy, foot.......... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
28060.............. Partial removal, foot .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
fascia.
28062.............. Removal of foot fascia.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28070.............. Removal of foot joint .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
lining.
28072.............. Removal of foot joint .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
lining.
28080.............. Removal of foot lesion.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28086.............. Excise foot tendon sheath. .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28088.............. Excise foot tendon sheath. .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28090.............. Removal of foot lesion.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28092.............. Removal of toe lesions.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28100.............. Removal of ankle/heel .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
lesion.
28102.............. Remove/graft foot lesion.. .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28103.............. Remove/graft foot lesion.. .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28104.............. Removal of foot lesion.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28106.............. Remove/graft foot lesion.. .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28107.............. Remove/graft foot lesion.. .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28108.............. Removal of toe lesions.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28110.............. Part removal of metatarsal .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28111.............. Part removal of metatarsal .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28112.............. Part removal of metatarsal .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28113.............. Part removal of metatarsal .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28114.............. Removal of metatarsal .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
heads.
28116.............. Revision of foot.......... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28118.............. Removal of heel bone...... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
[[Page 67021]]
28119.............. Removal of heel spur...... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28120.............. Part removal of ankle/heel .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28122.............. Partial removal of foot .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
bone.
28124.............. Partial removal of toe.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28126.............. Partial removal of toe.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28130.............. Removal of ankle bone..... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28140.............. Removal of metatarsal..... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28150.............. Removal of toe............ .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28153.............. Partial removal of toe.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28160.............. Partial removal of toe.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28171.............. Extensive foot surgery.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28173.............. Extensive foot surgery.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28175.............. Extensive foot surgery.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28190.............. Removal of foot foreign .................. T................. 0019 4.3039 $274.13 $71.87 $54.83
body.
28192.............. Removal of foot foreign .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
body.
28193.............. Removal of foot foreign .................. T................. 0020 8.6850 $553.18 ........... $110.64
body.
28200.............. Repair of foot tendon..... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28202.............. Repair/graft of foot .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
tendon.
28208.............. Repair of foot tendon..... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28210.............. Repair/graft of foot .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
tendon.
28220.............. Release of foot tendon.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28222.............. Release of foot tendons... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28225.............. Release of foot tendon.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28226.............. Release of foot tendons... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28230.............. Incision of foot tendon(s) .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28232.............. Incision of toe tendon.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28234.............. Incision of foot tendon... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28238.............. Revision of foot tendon... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28240.............. Release of big toe........ .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28250.............. Revision of foot fascia... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28260.............. Release of midfoot joint.. .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28261.............. Revision of foot tendon... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28262.............. Revision of foot and ankle .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28264.............. Release of midfoot joint.. .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28270.............. Release of foot .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
contracture.
28272.............. Release of toe joint, each .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28280.............. Fusion of toes............ .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28285.............. Repair of hammertoe....... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28286.............. Repair of hammertoe....... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28288.............. Partial removal of foot .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
bone.
28289.............. Repair hallux rigidus..... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28290.............. Correction of bunion...... .................. T................. 0057 29.4167 $1,873.67 $475.91 $374.73
28292.............. Correction of bunion...... .................. T................. 0057 29.4167 $1,873.67 $475.91 $374.73
28293.............. Correction of bunion...... .................. T................. 0057 29.4167 $1,873.67 $475.91 $374.73
28294.............. Correction of bunion...... .................. T................. 0057 29.4167 $1,873.67 $475.91 $374.73
28296.............. Correction of bunion...... .................. T................. 0057 29.4167 $1,873.67 $475.91 $374.73
28297.............. Correction of bunion...... .................. T................. 0057 29.4167 $1,873.67 $475.91 $374.73
28298.............. Correction of bunion...... .................. T................. 0057 29.4167 $1,873.67 $475.91 $374.73
28299.............. Correction of bunion...... .................. T................. 0057 29.4167 $1,873.67 $475.91 $374.73
28300.............. Incision of heel bone..... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28302.............. Incision of ankle bone.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28304.............. Incision of midfoot bones. .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28305.............. Incise/graft midfoot bones .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28306.............. Incision of metatarsal.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28307.............. Incision of metatarsal.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28308.............. Incision of metatarsal.... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28309.............. Incision of metatarsals... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28310.............. Revision of big toe....... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28312.............. Revision of toe........... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28313.............. Repair deformity of toe... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28315.............. Removal of sesamoid bone.. .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28320.............. Repair of foot bones...... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28322.............. Repair of metatarsals..... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28340.............. Resect enlarged toe tissue .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28341.............. Resect enlarged toe....... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28344.............. Repair extra toe(s)....... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28345.............. Repair webbed toe(s)...... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28360.............. Reconstruct cleft foot.... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28400.............. Treatment of heel fracture .................. T................. 0043 1.7682 $112.62 ........... $22.52
28405.............. Treatment of heel fracture .................. T................. 0043 1.7682 $112.62 ........... $22.52
28406.............. Treatment of heel fracture .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28415.............. Treat heel fracture....... CH................ T................. 0064 59.2233 $3,772.17 $835.79 $754.43
28420.............. Treat/graft heel fracture. .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
28430.............. Treatment of ankle .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
28435.............. Treatment of ankle .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
28436.............. Treatment of ankle .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
fracture.
28445.............. Treat ankle fracture...... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
28446.............. Osteochondral talus NI................ T................. 0056 44.2687 $2,819.65 ........... $563.93
autogrft.
28450.............. Treat midfoot fracture, .................. T................. 0043 1.7682 $112.62 ........... $22.52
each.
28455.............. Treat midfoot fracture, .................. T................. 0043 1.7682 $112.62 ........... $22.52
each.
[[Page 67022]]
28456.............. Treat midfoot fracture.... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28465.............. Treat midfoot fracture, .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
each.
28470.............. Treat metatarsal fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
28475.............. Treat metatarsal fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
28476.............. Treat metatarsal fracture. .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28485.............. Treat metatarsal fracture. .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
28490.............. Treat big toe fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
28495.............. Treat big toe fracture.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
28496.............. Treat big toe fracture.... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28505.............. Treat big toe fracture.... CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28510.............. Treatment of toe fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
28515.............. Treatment of toe fracture. .................. T................. 0043 1.7682 $112.62 ........... $22.52
28525.............. Treat toe fracture........ CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28530.............. Treat sesamoid bone .................. T................. 0043 1.7682 $112.62 ........... $22.52
fracture.
28531.............. Treat sesamoid bone CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
fracture.
28540.............. Treat foot dislocation.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
28545.............. Treat foot dislocation.... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28546.............. Treat foot dislocation.... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28555.............. Repair foot dislocation... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
28570.............. Treat foot dislocation.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
28575.............. Treat foot dislocation.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
28576.............. Treat foot dislocation.... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28585.............. Repair foot dislocation... CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28600.............. Treat foot dislocation.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
28605.............. Treat foot dislocation.... .................. T................. 0043 1.7682 $112.62 ........... $22.52
28606.............. Treat foot dislocation.... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28615.............. Repair foot dislocation... .................. T................. 0063 41.1091 $2,618.40 $548.33 $523.68
28630.............. Treat toe dislocation..... .................. T................. 0043 1.7682 $112.62 ........... $22.52
28635.............. Treat toe dislocation..... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
28636.............. Treat toe dislocation..... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28645.............. Repair toe dislocation.... CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28660.............. Treat toe dislocation..... .................. T................. 0043 1.7682 $112.62 ........... $22.52
28665.............. Treat toe dislocation..... .................. T................. 0045 14.7658 $940.49 $268.47 $188.10
28666.............. Treat toe dislocation..... .................. T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28675.............. Repair of toe dislocation. CH................ T................. 0062 26.1592 $1,666.18 $372.87 $333.24
28705.............. Fusion of foot bones...... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28715.............. Fusion of foot bones...... CH................ T................. 0052 79.4244 $5,058.86 ........... $1,011.77
28725.............. Fusion of foot bones...... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28730.............. Fusion of foot bones...... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28735.............. Fusion of foot bones...... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28737.............. Revision of foot bones.... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28740.............. Fusion of foot bones...... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28750.............. Fusion of big toe joint... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28755.............. Fusion of big toe joint... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28760.............. Fusion of big toe joint... .................. T................. 0056 44.2687 $2,819.65 ........... $563.93
28800.............. Amputation of midfoot..... .................. C................. ........... ........... ........... ........... ...........
28805.............. Amputation thru metatarsal .................. C................. ........... ........... ........... ........... ...........
28810.............. Amputation toe & .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
metatarsal.
28820.............. Amputation of toe......... .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28825.............. Partial amputation of toe. .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
28890.............. High energy eswt, plantar .................. T................. 0050 29.1900 $1,859.23 ........... $371.85
f.
28899.............. Foot/toes surgery .................. T................. 0043 1.7682 $112.62 ........... $22.52
procedure.
29000.............. Application of body cast.. .................. S................. 0058 1.0931 $69.62 ........... $13.92
29010.............. Application of body cast.. .................. S................. 0426 2.2910 $145.92 ........... $29.18
29015.............. Application of body cast.. .................. S................. 0426 2.2910 $145.92 ........... $29.18
29020.............. Application of body cast.. .................. S................. 0058 1.0931 $69.62 ........... $13.92
29025.............. Application of body cast.. .................. S................. 0058 1.0931 $69.62 ........... $13.92
29035.............. Application of body cast.. .................. S................. 0426 2.2910 $145.92 ........... $29.18
29040.............. Application of body cast.. .................. S................. 0058 1.0931 $69.62 ........... $13.92
29044.............. Application of body cast.. .................. S................. 0426 2.2910 $145.92 ........... $29.18
29046.............. Application of body cast.. .................. S................. 0426 2.2910 $145.92 ........... $29.18
29049.............. Application of figure .................. S................. 0058 1.0931 $69.62 ........... $13.92
eight.
29055.............. Application of shoulder .................. S................. 0426 2.2910 $145.92 ........... $29.18
cast.
29058.............. Application of shoulder .................. S................. 0058 1.0931 $69.62 ........... $13.92
cast.
29065.............. Application of long arm .................. S................. 0426 2.2910 $145.92 ........... $29.18
cast.
29075.............. Application of forearm .................. S................. 0426 2.2910 $145.92 ........... $29.18
cast.
29085.............. Apply hand/wrist cast..... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29086.............. Apply finger cast......... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29105.............. Apply long arm splint..... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29125.............. Apply forearm splint...... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29126.............. Apply forearm splint...... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29130.............. Application of finger .................. S................. 0058 1.0931 $69.62 ........... $13.92
splint.
29131.............. Application of finger .................. S................. 0058 1.0931 $69.62 ........... $13.92
splint.
29200.............. Strapping of chest........ .................. S................. 0058 1.0931 $69.62 ........... $13.92
29220.............. Strapping of low back..... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29240.............. Strapping of shoulder..... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29260.............. Strapping of elbow or .................. S................. 0058 1.0931 $69.62 ........... $13.92
wrist.
29280.............. Strapping of hand or .................. S................. 0058 1.0931 $69.62 ........... $13.92
finger.
29305.............. Application of hip cast... .................. S................. 0426 2.2910 $145.92 ........... $29.18
29325.............. Application of hip casts.. .................. S................. 0426 2.2910 $145.92 ........... $29.18
[[Page 67023]]
29345.............. Application of long leg .................. S................. 0426 2.2910 $145.92 ........... $29.18
cast.
29355.............. Application of long leg .................. S................. 0426 2.2910 $145.92 ........... $29.18
cast.
29358.............. Apply long leg cast brace. .................. S................. 0426 2.2910 $145.92 ........... $29.18
29365.............. Application of long leg .................. S................. 0426 2.2910 $145.92 ........... $29.18
cast.
29405.............. Apply short leg cast...... .................. S................. 0426 2.2910 $145.92 ........... $29.18
29425.............. Apply short leg cast...... .................. S................. 0426 2.2910 $145.92 ........... $29.18
29435.............. Apply short leg cast...... .................. S................. 0426 2.2910 $145.92 ........... $29.18
29440.............. Addition of walker to cast .................. S................. 0058 1.0931 $69.62 ........... $13.92
29445.............. Apply rigid leg cast...... .................. S................. 0426 2.2910 $145.92 ........... $29.18
29450.............. Application of leg cast... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29505.............. Application, long leg .................. S................. 0058 1.0931 $69.62 ........... $13.92
splint.
29515.............. Application lower leg .................. S................. 0058 1.0931 $69.62 ........... $13.92
splint.
29520.............. Strapping of hip.......... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29530.............. Strapping of knee......... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29540.............. Strapping of ankle and/or .................. S................. 0058 1.0931 $69.62 ........... $13.92
ft.
29550.............. Strapping of toes......... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29580.............. Application of paste boot. .................. S................. 0058 1.0931 $69.62 ........... $13.92
29590.............. Application of foot splint .................. S................. 0058 1.0931 $69.62 ........... $13.92
29700.............. Removal/revision of cast.. .................. S................. 0058 1.0931 $69.62 ........... $13.92
29705.............. Removal/revision of cast.. .................. S................. 0058 1.0931 $69.62 ........... $13.92
29710.............. Removal/revision of cast.. .................. S................. 0426 2.2910 $145.92 ........... $29.18
29715.............. Removal/revision of cast.. .................. S................. 0058 1.0931 $69.62 ........... $13.92
29720.............. Repair of body cast....... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29730.............. Windowing of cast......... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29740.............. Wedging of cast........... .................. S................. 0058 1.0931 $69.62 ........... $13.92
29750.............. Wedging of clubfoot cast.. .................. S................. 0058 1.0931 $69.62 ........... $13.92
29799.............. Casting/strapping .................. S................. 0058 1.0931 $69.62 ........... $13.92
procedure.
29800.............. Jaw arthroscopy/surgery... .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29804.............. Jaw arthroscopy/surgery... .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29805.............. Shoulder arthroscopy, dx.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29806.............. Shoulder arthroscopy/ .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
surgery.
29807.............. Shoulder arthroscopy/ .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
surgery.
29819.............. Shoulder arthroscopy/ CH................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
surgery.
29820.............. Shoulder arthroscopy/ CH................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
surgery.
29821.............. Shoulder arthroscopy/ CH................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
surgery.
29822.............. Shoulder arthroscopy/ .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
surgery.
29823.............. Shoulder arthroscopy/ CH................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
surgery.
29824.............. Shoulder arthroscopy/ .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
surgery.
29825.............. Shoulder arthroscopy/ CH................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
surgery.
29826.............. Shoulder arthroscopy/ .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
surgery.
29827.............. Arthroscop rotator cuff .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
repr.
29828.............. Arthroscopy biceps NI................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
tenodesis.
29830.............. Elbow arthroscopy......... .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29834.............. Elbow arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29835.............. Elbow arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29836.............. Elbow arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29837.............. Elbow arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29838.............. Elbow arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29840.............. Wrist arthroscopy......... .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29843.............. Wrist arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29844.............. Wrist arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29845.............. Wrist arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29846.............. Wrist arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29847.............. Wrist arthroscopy/surgery. CH................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29848.............. Wrist endoscopy/surgery... .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29850.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29851.............. Knee arthroscopy/surgery.. .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29855.............. Tibial arthroscopy/surgery .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29856.............. Tibial arthroscopy/surgery CH................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29860.............. Hip arthroscopy, dx....... CH................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29861.............. Hip arthroscopy/surgery... CH................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29862.............. Hip arthroscopy/surgery... .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29863.............. Hip arthroscopy/surgery... .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29866.............. Autgrft implnt, knee w/ .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
scope.
29867.............. Allgrft implnt, knee w/ .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
scope.
29868.............. Meniscal trnspl, knee w/ .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
scpe.
29870.............. Knee arthroscopy, dx...... .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29871.............. Knee arthroscopy/drainage. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29873.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29874.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29875.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29876.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29877.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29879.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29880.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29881.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29882.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29883.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29884.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29885.............. Knee arthroscopy/surgery.. .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
[[Page 67024]]
29886.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29887.............. Knee arthroscopy/surgery.. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29888.............. Knee arthroscopy/surgery.. .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29889.............. Knee arthroscopy/surgery.. .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29891.............. Ankle arthroscopy/surgery. CH................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29892.............. Ankle arthroscopy/surgery. CH................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29893.............. Scope, plantar fasciotomy. .................. T................. 0055 20.8284 $1,326.64 $355.34 $265.33
29894.............. Ankle arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29895.............. Ankle arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29897.............. Ankle arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29898.............. Ankle arthroscopy/surgery. .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
29899.............. Ankle arthroscopy/surgery. .................. T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29900.............. Mcp joint arthroscopy, dx. CH................ T................. 0041 28.7803 $1,833.13 ........... $366.63
29901.............. Mcp joint arthroscopy, CH................ T................. 0041 28.7803 $1,833.13 ........... $366.63
surg.
29902.............. Mcp joint arthroscopy, CH................ T................. 0041 28.7803 $1,833.13 ........... $366.63
surg.
29904.............. Subtalar arthro w/fb rmvl. NI................ T................. 0041 28.7803 $1,833.13 ........... $366.63
29905.............. Subtalar arthro w/exc..... NI................ T................. 0041 28.7803 $1,833.13 ........... $366.63
29906.............. Subtalar arthro w/deb..... NI................ T................. 0041 28.7803 $1,833.13 ........... $366.63
29907.............. Subtalar arthro w/fusion.. NI................ T................. 0042 45.7072 $2,911.27 $804.74 $582.25
29999.............. Arthroscopy of joint...... .................. T................. 0041 28.7803 $1,833.13 ........... $366.63
30000.............. Drainage of nose lesion... .................. T................. 0251 2.5002 $159.25 ........... $31.85
30020.............. Drainage of nose lesion... .................. T................. 0251 2.5002 $159.25 ........... $31.85
3006F.............. Cxr doc rev............... .................. M................. ........... ........... ........... ........... ...........
30100.............. Intranasal biopsy......... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
30110.............. Removal of nose polyp(s).. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
30115.............. Removal of nose polyp(s).. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
30117.............. Removal of intranasal .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
lesion.
30118.............. Removal of intranasal .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
lesion.
3011F.............. Lipid panel doc rev....... .................. M................. ........... ........... ........... ........... ...........
30120.............. Revision of nose.......... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
30124.............. Removal of nose lesion.... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
30125.............. Removal of nose lesion.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
30130.............. Excise inferior turbinate. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
30140.............. Resect inferior turbinate. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
3014F.............. Screen mammo doc rev...... .................. M................. ........... ........... ........... ........... ...........
30150.............. Partial removal of nose... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
30160.............. Removal of nose........... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3017F.............. Colorectal ca screen doc .................. M................. ........... ........... ........... ........... ...........
rev.
30200.............. Injection treatment of .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
nose.
3020F.............. Lvf assess................ .................. M................. ........... ........... ........... ........... ...........
30210.............. Nasal sinus therapy....... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
3021F.............. Lvef mod/sever deprs syst. .................. M................. ........... ........... ........... ........... ...........
30220.............. Insert nasal septal button .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
3022F.............. Lvef >=40% systolic....... .................. M................. ........... ........... ........... ........... ...........
3023F.............. Spirom doc rev............ .................. M................. ........... ........... ........... ........... ...........
3025F.............. Spirom fev/fvc<70% w copd. .................. M................. ........... ........... ........... ........... ...........
3027F.............. Spirom fev/fvc>=70%/w/o .................. M................. ........... ........... ........... ........... ...........
copd.
3028F.............. O2 saturation doc rev..... .................. M................. ........... ........... ........... ........... ...........
30300.............. Remove nasal foreign body. .................. X................. 0340 0.6310 $40.19 ........... $8.04
30310.............. Remove nasal foreign body. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
30320.............. Remove nasal foreign body. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
3035F.............. O2 saturation<=88% / .................. M................. ........... ........... ........... ........... ...........
pao<=55.
3037F.............. O2 saturation >88% /pao>55 .................. M................. ........... ........... ........... ........... ...........
30400.............. Reconstruction of nose.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3040F.............. Fev<40% predicted value... .................. M................. ........... ........... ........... ........... ...........
30410.............. Reconstruction of nose.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
30420.............. Reconstruction of nose.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3042F.............. Fev>= 40% predicted value. .................. M................. ........... ........... ........... ........... ...........
30430.............. Revision of nose.......... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
30435.............. Revision of nose.......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3044F.............. Hg a1c level lt 7.0%...... .................. M................. ........... ........... ........... ........... ...........
30450.............. Revision of nose.......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3045F.............. HG a1c level 7.0-9.0%..... .................. M................. ........... ........... ........... ........... ...........
30460.............. Revision of nose.......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
30462.............. Revision of nose.......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
30465.............. Repair nasal stenosis..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3046F.............. Hemoglobin a1c level > .................. M................. ........... ........... ........... ........... ...........
9.0%.
3048F.............. Ldl-c <100 mg/dl.......... .................. M................. ........... ........... ........... ........... ...........
3049F.............. Ldl-c 100-129 mg/dl....... .................. M................. ........... ........... ........... ........... ...........
3050F.............. Ldl-c >= 130 mg/dl........ .................. M................. ........... ........... ........... ........... ...........
30520.............. Repair of nasal septum.... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
30540.............. Repair nasal defect....... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
30545.............. Repair nasal defect....... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
30560.............. Release of nasal adhesions .................. T................. 0251 2.5002 $159.25 ........... $31.85
30580.............. Repair upper jaw fistula.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
30600.............. Repair mouth/nose fistula. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3060F.............. Pos microalbuminuria rev.. .................. M................. ........... ........... ........... ........... ...........
3061F.............. Neg microalbuminuria rev.. .................. M................. ........... ........... ........... ........... ...........
30620.............. Intranasal reconstruction. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3062F.............. Pos macroalbuminuria rev.. .................. M................. ........... ........... ........... ........... ...........
[[Page 67025]]
30630.............. Repair nasal septum defect .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
3066F.............. Nephropathy doc tx........ .................. M................. ........... ........... ........... ........... ...........
3072F.............. Low risk for retinopathy.. .................. M................. ........... ........... ........... ........... ...........
3073F.............. Pre-surg eye measures .................. M................. ........... ........... ........... ........... ...........
doc'd.
3074F.............. Syst bp lt 130 mm hg...... .................. M................. ........... ........... ........... ........... ...........
3075F.............. Syst bp ge 130 - 139mm hg. .................. M................. ........... ........... ........... ........... ...........
3077F.............. Syst bp >= 140 mm hg6 it.. .................. M................. ........... ........... ........... ........... ...........
3078F.............. Diast bp < 80 mm hg....... .................. M................. ........... ........... ........... ........... ...........
3079F.............. Diast bp 80-89 mm hg...... .................. M................. ........... ........... ........... ........... ...........
30801.............. Ablate inf turbinate, .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
superf.
30802.............. Cauterization, inner nose. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
3080F.............. Diast bp >= 90 mm hg...... .................. M................. ........... ........... ........... ........... ...........
3082F.............. Kt/v lt 1.2............... .................. M................. ........... ........... ........... ........... ...........
3083F.............. Kt/v ge 1.2 and <1.7...... .................. M................. ........... ........... ........... ........... ...........
3084F.............. Kt/v ge 1.7............... .................. M................. ........... ........... ........... ........... ...........
3085F.............. Suicide risk assessed..... .................. M................. ........... ........... ........... ........... ...........
3088F.............. MDD, mild................. .................. M................. ........... ........... ........... ........... ...........
3089F.............. MDD, moderate............. .................. M................. ........... ........... ........... ........... ...........
30901.............. Control of nosebleed...... .................. T................. 0250 1.1251 $71.66 $25.10 $14.33
30903.............. Control of nosebleed...... .................. T................. 0250 1.1251 $71.66 $25.10 $14.33
30905.............. Control of nosebleed...... .................. T................. 0250 1.1251 $71.66 $25.10 $14.33
30906.............. Repeat control of .................. T................. 0250 1.1251 $71.66 $25.10 $14.33
nosebleed.
3090F.............. MDD, severe; w/o psych.... .................. M................. ........... ........... ........... ........... ...........
30915.............. Ligation, nasal sinus .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
artery.
3091F.............. Mdd, severe; w/ psych..... .................. M................. ........... ........... ........... ........... ...........
30920.............. Ligation, upper jaw artery .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
3092F.............. MDD, in remission......... .................. M................. ........... ........... ........... ........... ...........
30930.............. Ther fx, nasal inf .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
turbinate.
3093F.............. Doc new diag 1st/addl mdd. .................. M................. ........... ........... ........... ........... ...........
3095F.............. Central dexa results doc'd .................. M................. ........... ........... ........... ........... ...........
3096F.............. Central dexa ordered...... .................. M................. ........... ........... ........... ........... ...........
30999.............. Nasal surgery procedure... .................. T................. 0251 2.5002 $159.25 ........... $31.85
31000.............. Irrigation, maxillary .................. T................. 0251 2.5002 $159.25 ........... $31.85
sinus.
31002.............. Irrigation, sphenoid sinus .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
3100F.............. Image test ref carot diam. .................. M................. ........... ........... ........... ........... ...........
31020.............. Exploration, maxillary .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
sinus.
31030.............. Exploration, maxillary .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
sinus.
31032.............. Explore sinus, remove .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
polyps.
31040.............. Exploration behind upper .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
jaw.
31050.............. Exploration, sphenoid .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
sinus.
31051.............. Sphenoid sinus surgery.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31070.............. Exploration of frontal .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
sinus.
31075.............. Exploration of frontal .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
sinus.
31080.............. Removal of frontal sinus.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31081.............. Removal of frontal sinus.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31084.............. Removal of frontal sinus.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31085.............. Removal of frontal sinus.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31086.............. Removal of frontal sinus.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31087.............. Removal of frontal sinus.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31090.............. Exploration of sinuses.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3110F.............. Pres/absn hmrhg/lesion .................. M................. ........... ........... ........... ........... ...........
doc'd.
3111F.............. Ct/mri brain done w/in .................. M................. ........... ........... ........... ........... ...........
24hrs.
3112F.............. Ct/mri brain done gt 24 .................. M................. ........... ........... ........... ........... ...........
hrs.
31200.............. Removal of ethmoid sinus.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31201.............. Removal of ethmoid sinus.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31205.............. Removal of ethmoid sinus.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3120F.............. 12-lead ecg performed..... .................. M................. ........... ........... ........... ........... ...........
31225.............. Removal of upper jaw...... .................. C................. ........... ........... ........... ........... ...........
31230.............. Removal of upper jaw...... .................. C................. ........... ........... ........... ........... ...........
31231.............. Nasal endoscopy, dx....... .................. T................. 0072 1.6115 $102.64 $21.27 $20.53
31233.............. Nasal/sinus endoscopy, dx. .................. T................. 0072 1.6115 $102.64 $21.27 $20.53
31235.............. Nasal/sinus endoscopy, dx. .................. T................. 0074 17.0160 $1,083.82 $292.25 $216.76
31237.............. Nasal/sinus endoscopy, .................. T................. 0074 17.0160 $1,083.82 $292.25 $216.76
surg.
31238.............. Nasal/sinus endoscopy, .................. T................. 0074 17.0160 $1,083.82 $292.25 $216.76
surg.
31239.............. Nasal/sinus endoscopy, .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
surg.
31240.............. Nasal/sinus endoscopy, .................. T................. 0074 17.0160 $1,083.82 $292.25 $216.76
surg.
31254.............. Revision of ethmoid sinus. .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
31255.............. Removal of ethmoid sinus.. .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
31256.............. Exploration maxillary .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
sinus.
31267.............. Endoscopy, maxillary sinus .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
31276.............. Sinus endoscopy, surgical. .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
31287.............. Nasal/sinus endoscopy, .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
surg.
31288.............. Nasal/sinus endoscopy, .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
surg.
31290.............. Nasal/sinus endoscopy, .................. C................. ........... ........... ........... ........... ...........
surg.
31291.............. Nasal/sinus endoscopy, .................. C................. ........... ........... ........... ........... ...........
surg.
31292.............. Nasal/sinus endoscopy, .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
surg.
31293.............. Nasal/sinus endoscopy, .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
surg.
31294.............. Nasal/sinus endoscopy, .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
surg.
31299.............. Sinus surgery procedure... .................. T................. 0251 2.5002 $159.25 ........... $31.85
31300.............. Removal of larynx lesion.. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
[[Page 67026]]
3130F.............. Upper gi endoscopy .................. M................. ........... ........... ........... ........... ...........
performed.
31320.............. Diagnostic incision, .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
larynx.
3132F.............. Doc ref upper gi endoscopy .................. M................. ........... ........... ........... ........... ...........
31360.............. Removal of larynx......... .................. C................. ........... ........... ........... ........... ...........
31365.............. Removal of larynx......... .................. C................. ........... ........... ........... ........... ...........
31367.............. Partial removal of larynx. .................. C................. ........... ........... ........... ........... ...........
31368.............. Partial removal of larynx. .................. C................. ........... ........... ........... ........... ...........
31370.............. Partial removal of larynx. .................. C................. ........... ........... ........... ........... ...........
31375.............. Partial removal of larynx. .................. C................. ........... ........... ........... ........... ...........
31380.............. Partial removal of larynx. .................. C................. ........... ........... ........... ........... ...........
31382.............. Partial removal of larynx. .................. C................. ........... ........... ........... ........... ...........
31390.............. Removal of larynx & .................. C................. ........... ........... ........... ........... ...........
pharynx.
31395.............. Reconstruct larynx & .................. C................. ........... ........... ........... ........... ...........
pharynx.
31400.............. Revision of larynx........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3140F.............. Upper gi endo shows .................. M................. ........... ........... ........... ........... ...........
barrtt's.
3141F.............. Upper gi endo not barrtt's .................. M................. ........... ........... ........... ........... ...........
31420.............. Removal of epiglottis..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
3142F.............. Barium swallow test .................. M................. ........... ........... ........... ........... ...........
ordered.
31500.............. Insert emergency airway... .................. S................. 0094 2.4590 $156.62 $46.29 $31.32
31502.............. Change of windpipe airway. CH................ S................. 0078 1.3362 $85.11 ........... $17.02
31505.............. Diagnostic laryngoscopy... .................. T................. 0071 0.8224 $52.38 $11.20 $10.48
3150F.............. Forceps esoph biopsy done. .................. M................. ........... ........... ........... ........... ...........
31510.............. Laryngoscopy with biopsy.. .................. T................. 0074 17.0160 $1,083.82 $292.25 $216.76
31511.............. Remove foreign body, .................. T................. 0072 1.6115 $102.64 $21.27 $20.53
larynx.
31512.............. Removal of larynx lesion.. .................. T................. 0074 17.0160 $1,083.82 $292.25 $216.76
31513.............. Injection into vocal cord. .................. T................. 0072 1.6115 $102.64 $21.27 $20.53
31515.............. Laryngoscopy for .................. T................. 0074 17.0160 $1,083.82 $292.25 $216.76
aspiration.
31520.............. Dx laryngoscopy, newborn.. .................. T................. 0072 1.6115 $102.64 $21.27 $20.53
31525.............. Dx laryngoscopy excl nb... .................. T................. 0074 17.0160 $1,083.82 $292.25 $216.76
31526.............. Dx laryngoscopy w/oper .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
scope.
31527.............. Laryngoscopy for treatment .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
31528.............. Laryngoscopy and dilation. .................. T................. 0074 17.0160 $1,083.82 $292.25 $216.76
31529.............. Laryngoscopy and dilation. .................. T................. 0074 17.0160 $1,083.82 $292.25 $216.76
31530.............. Laryngoscopy w/fb removal. .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
31531.............. Laryngoscopy w/fb & op .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
scope.
31535.............. Laryngoscopy w/biopsy..... .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
31536.............. Laryngoscopy w/bx & op .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
scope.
31540.............. Laryngoscopy w/exc of .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
tumor.
31541.............. Larynscop w/tumr exc + .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
scope.
31545.............. Remove vc lesion w/scope.. .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
31546.............. Remove vc lesion scope/ .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
graft.
3155F.............. Cytogen test marrow b/4 tx .................. M................. ........... ........... ........... ........... ...........
31560.............. Laryngoscop w/ .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
arytenoidectom.
31561.............. Larynscop, remve cart + .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
scop.
31570.............. Laryngoscope w/vc inj..... .................. T................. 0074 17.0160 $1,083.82 $292.25 $216.76
31571.............. Laryngoscop w/vc inj + .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
scope.
31575.............. Diagnostic laryngoscopy... .................. T................. 0072 1.6115 $102.64 $21.27 $20.53
31576.............. Laryngoscopy with biopsy.. .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
31577.............. Remove foreign body, .................. T................. 0073 3.9940 $254.39 $69.15 $50.88
larynx.
31578.............. Removal of larynx lesion.. .................. T................. 0075 22.7191 $1,447.07 $445.92 $289.41
31579.............. Diagnostic laryngoscopy... .................. T................. 0073 3.9940 $254.39 $69.15 $50.88
31580.............. Revision of larynx........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31582.............. Revision of larynx........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31584.............. Treat larynx fracture..... .................. C................. ........... ........... ........... ........... ...........
31587.............. Revision of larynx........ .................. C................. ........... ........... ........... ........... ...........
31588.............. Revision of larynx........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31590.............. Reinnervate larynx........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31595.............. Larynx nerve surgery...... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31599.............. Larynx surgery procedure.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
31600.............. Incision of windpipe...... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
31601.............. Incision of windpipe...... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
31603.............. Incision of windpipe...... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
31605.............. Incision of windpipe...... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
3160F.............. Doc fe+ stores b/4 epo thx .................. M................. ........... ........... ........... ........... ...........
31610.............. Incision of windpipe...... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
31611.............. Surgery/speech prosthesis. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
31612.............. Puncture/clear windpipe... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
31613.............. Repair windpipe opening... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
31614.............. Repair windpipe opening... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31615.............. Visualization of windpipe. .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
31620.............. Endobronchial us add-on... CH................ N................. ........... ........... ........... ........... ...........
31622.............. Dx bronchoscope/wash...... .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
31623.............. Dx bronchoscope/brush..... .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
31624.............. Dx bronchoscope/lavage.... .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
31625.............. Bronchoscopy w/biopsy(s).. .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
31628.............. Bronchoscopy/lung bx, each .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
31629.............. Bronchoscopy/needle bx, .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
each.
31630.............. Bronchoscopy dilate/fx .................. T................. 0415 24.0654 $1,532.82 $459.92 $306.56
repr.
31631.............. Bronchoscopy, dilate w/ .................. T................. 0415 24.0654 $1,532.82 $459.92 $306.56
stent.
31632.............. Bronchoscopy/lung bx, .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
add'l.
[[Page 67027]]
31633.............. Bronchoscopy/needle bx .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
add'l.
31635.............. Bronchoscopy w/fb removal. .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
31636.............. Bronchoscopy, bronch .................. T................. 0415 24.0654 $1,532.82 $459.92 $306.56
stents.
31637.............. Bronchoscopy, stent add-on .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
31638.............. Bronchoscopy, revise stent .................. T................. 0415 24.0654 $1,532.82 $459.92 $306.56
31640.............. Bronchoscopy w/tumor .................. T................. 0415 24.0654 $1,532.82 $459.92 $306.56
excise.
31641.............. Bronchoscopy, treat .................. T................. 0415 24.0654 $1,532.82 $459.92 $306.56
blockage.
31643.............. Diag bronchoscope/catheter .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
31645.............. Bronchoscopy, clear .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
airways.
31646.............. Bronchoscopy, reclear .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
airway.
31656.............. Bronchoscopy, inj for x- .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
ray.
3170F.............. Flow cyto done b/4 tx..... .................. M................. ........... ........... ........... ........... ...........
31715.............. Injection for bronchus x- .................. N................. ........... ........... ........... ........... ...........
ray.
31717.............. Bronchial brush biopsy.... .................. T................. 0073 3.9940 $254.39 $69.15 $50.88
31720.............. Clearance of airways...... CH................ S................. 0077 0.3877 $24.69 $7.74 $4.94
31725.............. Clearance of airways...... .................. C................. ........... ........... ........... ........... ...........
31730.............. Intro, windpipe wire/tube. .................. T................. 0073 3.9940 $254.39 $69.15 $50.88
31750.............. Repair of windpipe........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31755.............. Repair of windpipe........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
31760.............. Repair of windpipe........ .................. C................. ........... ........... ........... ........... ...........
31766.............. Reconstruction of windpipe .................. C................. ........... ........... ........... ........... ...........
31770.............. Repair/graft of bronchus.. .................. C................. ........... ........... ........... ........... ...........
31775.............. Reconstruct bronchus...... .................. C................. ........... ........... ........... ........... ...........
31780.............. Reconstruct windpipe...... .................. C................. ........... ........... ........... ........... ...........
31781.............. Reconstruct windpipe...... .................. C................. ........... ........... ........... ........... ...........
31785.............. Remove windpipe lesion.... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
31786.............. Remove windpipe lesion.... .................. C................. ........... ........... ........... ........... ...........
31800.............. Repair of windpipe injury. .................. C................. ........... ........... ........... ........... ...........
31805.............. Repair of windpipe injury. .................. C................. ........... ........... ........... ........... ...........
31820.............. Closure of windpipe lesion .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
31825.............. Repair of windpipe defect. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
31830.............. Revise windpipe scar...... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
31899.............. Airways surgical procedure .................. T................. 0076 9.9575 $634.23 $189.82 $126.85
32000.............. Drainage of chest......... CH................ D................. ........... ........... ........... ........... ...........
32002.............. Treatment of collapsed CH................ D................. ........... ........... ........... ........... ...........
lung.
32005.............. Treat lung lining CH................ D................. ........... ........... ........... ........... ...........
chemically.
3200F.............. Barium swallow test not .................. M................. ........... ........... ........... ........... ...........
req.
32019.............. Insert pleural catheter... CH................ D................. ........... ........... ........... ........... ...........
32020.............. Insertion of chest tube... CH................ D................. ........... ........... ........... ........... ...........
32035.............. Exploration of chest...... .................. C................. ........... ........... ........... ........... ...........
32036.............. Exploration of chest...... .................. C................. ........... ........... ........... ........... ...........
32095.............. Biopsy through chest wall. .................. C................. ........... ........... ........... ........... ...........
32100.............. Exploration/biopsy of .................. C................. ........... ........... ........... ........... ...........
chest.
3210F.............. Grp a strep test performed .................. M................. ........... ........... ........... ........... ...........
32110.............. Explore/repair chest...... .................. C................. ........... ........... ........... ........... ...........
32120.............. Re-exploration of chest... .................. C................. ........... ........... ........... ........... ...........
32124.............. Explore chest free .................. C................. ........... ........... ........... ........... ...........
adhesions.
32140.............. Removal of lung lesion(s). .................. C................. ........... ........... ........... ........... ...........
32141.............. Remove/treat lung lesions. .................. C................. ........... ........... ........... ........... ...........
32150.............. Removal of lung lesion(s). .................. C................. ........... ........... ........... ........... ...........
32151.............. Remove lung foreign body.. .................. C................. ........... ........... ........... ........... ...........
3215F.............. Pt immunity to hep A doc'd .................. M................. ........... ........... ........... ........... ...........
32160.............. Open chest heart massage.. .................. C................. ........... ........... ........... ........... ...........
3216F.............. Pt immunity to hep B doc'd .................. M................. ........... ........... ........... ........... ...........
3218F.............. Rna tstng hep c doc'd-done .................. M................. ........... ........... ........... ........... ...........
32200.............. Drain, open, lung lesion.. .................. C................. ........... ........... ........... ........... ...........
32201.............. Drain, percut, lung lesion .................. T................. 0070 5.2024 $331.36 ........... $66.27
3220F.............. Hep C quant rna tstng .................. M................. ........... ........... ........... ........... ...........
doc'd.
32215.............. Treat chest lining........ .................. C................. ........... ........... ........... ........... ...........
32220.............. Release of lung........... .................. C................. ........... ........... ........... ........... ...........
32225.............. Partial release of lung... .................. C................. ........... ........... ........... ........... ...........
3230F.............. Note hring tst w/in 6 mon. .................. M................. ........... ........... ........... ........... ...........
32310.............. Removal of chest lining... .................. C................. ........... ........... ........... ........... ...........
32320.............. Free/remove chest lining.. .................. C................. ........... ........... ........... ........... ...........
32400.............. Needle biopsy chest lining .................. T................. 0685 9.3354 $594.61 ........... $118.92
32402.............. Open biopsy chest lining.. .................. C................. ........... ........... ........... ........... ...........
32405.............. Biopsy, lung or .................. T................. 0685 9.3354 $594.61 ........... $118.92
mediastinum.
32420.............. Puncture/clear lung....... .................. T................. 0070 5.2024 $331.36 ........... $66.27
32421.............. Thoracentesis for NI................ T................. 0070 5.2024 $331.36 ........... $66.27
aspiration.
32422.............. Thoracentesis w/tube NI................ T................. 0070 5.2024 $331.36 ........... $66.27
insert.
32440.............. Removal of lung........... .................. C................. ........... ........... ........... ........... ...........
32442.............. Sleeve pneumonectomy...... .................. C................. ........... ........... ........... ........... ...........
32445.............. Removal of lung........... .................. C................. ........... ........... ........... ........... ...........
32480.............. Partial removal of lung... .................. C................. ........... ........... ........... ........... ...........
32482.............. Bilobectomy............... .................. C................. ........... ........... ........... ........... ...........
32484.............. Segmentectomy............. .................. C................. ........... ........... ........... ........... ...........
32486.............. Sleeve lobectomy.......... .................. C................. ........... ........... ........... ........... ...........
32488.............. Completion pneumonectomy.. .................. C................. ........... ........... ........... ........... ...........
32491.............. Lung volume reduction..... .................. C................. ........... ........... ........... ........... ...........
32500.............. Partial removal of lung... .................. C................. ........... ........... ........... ........... ...........
[[Page 67028]]
32501.............. Repair bronchus add-on.... .................. C................. ........... ........... ........... ........... ...........
32503.............. Resect apical lung tumor.. .................. C................. ........... ........... ........... ........... ...........
32504.............. Resect apical lung tum/ .................. C................. ........... ........... ........... ........... ...........
chest.
32540.............. Removal of lung lesion.... .................. C................. ........... ........... ........... ........... ...........
32550.............. Insert pleural cath....... NI................ T................. 0652 30.7096 $1,956.02 ........... $391.20
32551.............. Insertion of chest tube... NI................ T................. 0070 5.2024 $331.36 ........... $66.27
32560.............. Treat lung lining NI................ T................. 0070 5.2024 $331.36 ........... $66.27
chemically.
32601.............. Thoracoscopy, diagnostic.. .................. T................. 0069 32.5666 $2,074.30 $591.64 $414.86
32602.............. Thoracoscopy, diagnostic.. .................. T................. 0069 32.5666 $2,074.30 $591.64 $414.86
32603.............. Thoracoscopy, diagnostic.. .................. T................. 0069 32.5666 $2,074.30 $591.64 $414.86
32604.............. Thoracoscopy, diagnostic.. .................. T................. 0069 32.5666 $2,074.30 $591.64 $414.86
32605.............. Thoracoscopy, diagnostic.. .................. T................. 0069 32.5666 $2,074.30 $591.64 $414.86
32606.............. Thoracoscopy, diagnostic.. .................. T................. 0069 32.5666 $2,074.30 $591.64 $414.86
3260F.............. Pt cat/pn cat/hist grd .................. M................. ........... ........... ........... ........... ...........
doc'd.
32650.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32651.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32652.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32653.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32654.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32655.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32656.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32657.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32658.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32659.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
3265F.............. RNA tstng HepC vir ord/ NI................ M................. ........... ........... ........... ........... ...........
doc'd.
32660.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32661.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32662.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32663.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32664.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
32665.............. Thoracoscopy, surgical.... .................. C................. ........... ........... ........... ........... ...........
3266F.............. HepC gn tstng doc'd b/ NI................ M................. ........... ........... ........... ........... ...........
4txmnt.
3268F.............. PSA/T/G1Sc doc'd b/4 txmnt NI................ M................. ........... ........... ........... ........... ...........
3269F.............. Bone scn b/4 txmnt/aftr Dx NI................ M................. ........... ........... ........... ........... ...........
3270F.............. No bone scn b/4 txmnt/ NI................ M................. ........... ........... ........... ........... ...........
aftrDx.
3271F.............. Low risk, prostate cancer. NI................ M................. ........... ........... ........... ........... ...........
3272F.............. Med. risk, prostate cancer NI................ M................. ........... ........... ........... ........... ...........
3273F.............. High risk, prostate cancer NI................ M................. ........... ........... ........... ........... ...........
3274F.............. Prost Cncr rsk not lw/md/ NI................ M................. ........... ........... ........... ........... ...........
hgh.
3278F.............. Serum lvls CA/iPTH/lpd ord NI................ M................. ........... ........... ........... ........... ...........
3279F.............. Hgb lvl >/=13 g/dL........ NI................ M................. ........... ........... ........... ........... ...........
32800.............. Repair lung hernia........ .................. C................. ........... ........... ........... ........... ...........
3280F.............. Hgb lvl 11-12.9 g/dL...... NI................ M................. ........... ........... ........... ........... ...........
32810.............. Close chest after drainage .................. C................. ........... ........... ........... ........... ...........
32815.............. Close bronchial fistula... .................. C................. ........... ........... ........... ........... ...........
3281F.............. Hgb lvl <11 g/dL.......... NI................ M................. ........... ........... ........... ........... ...........
32820.............. Reconstruct injured chest. .................. C................. ........... ........... ........... ........... ...........
3284F.............. IOP down >15% of pre-svc NI................ M................. ........... ........... ........... ........... ...........
lvl.
32850.............. Donor pneumonectomy....... .................. C................. ........... ........... ........... ........... ...........
32851.............. Lung transplant, single... .................. C................. ........... ........... ........... ........... ...........
32852.............. Lung transplant with .................. C................. ........... ........... ........... ........... ...........
bypass.
32853.............. Lung transplant, double... .................. C................. ........... ........... ........... ........... ...........
32854.............. Lung transplant with .................. C................. ........... ........... ........... ........... ...........
bypass.
32855.............. Prepare donor lung, single .................. C................. ........... ........... ........... ........... ...........
32856.............. Prepare donor lung, double .................. C................. ........... ........... ........... ........... ...........
3285F.............. IOP down <15% of pre-svc NI................ M................. ........... ........... ........... ........... ...........
lvl.
3288F.............. Fall risk assessment doc'd NI................ M................. ........... ........... ........... ........... ...........
32900.............. Removal of rib(s)......... .................. C................. ........... ........... ........... ........... ...........
32905.............. Revise & repair chest wall .................. C................. ........... ........... ........... ........... ...........
32906.............. Revise & repair chest wall .................. C................. ........... ........... ........... ........... ...........
3290F.............. Pt=D(Rh)- and unsensitized NI................ M................. ........... ........... ........... ........... ...........
3291F.............. Pt=D(Rh)+or sensitized.... NI................ M................. ........... ........... ........... ........... ...........
3292F.............. HIV tstng asked/doc'd/ NI................ M................. ........... ........... ........... ........... ...........
revw'd.
32940.............. Revision of lung.......... .................. C................. ........... ........... ........... ........... ...........
32960.............. Therapeutic pneumothorax.. .................. T................. 0070 5.2024 $331.36 ........... $66.27
32997.............. Total lung lavage......... .................. C................. ........... ........... ........... ........... ...........
32998.............. Perq rf ablate tx, pul .................. T................. 0423 42.9980 $2,738.71 ........... $547.74
tumor.
32999.............. Chest surgery procedure... .................. T................. 0070 5.2024 $331.36 ........... $66.27
3300F.............. AJCC stage doc'd b/4 thxpy NI................ M................. ........... ........... ........... ........... ...........
33010.............. Drainage of heart sac..... .................. T................. 0070 5.2024 $331.36 ........... $66.27
33011.............. Repeat drainage of heart .................. T................. 0070 5.2024 $331.36 ........... $66.27
sac.
33015.............. Incision of heart sac..... .................. C................. ........... ........... ........... ........... ...........
3301F.............. Cancer stage doc'd, metast NI................ M................. ........... ........... ........... ........... ...........
33020.............. Incision of heart sac..... .................. C................. ........... ........... ........... ........... ...........
33025.............. Incision of heart sac..... .................. C................. ........... ........... ........... ........... ...........
3302F.............. AJCC stage 0 doc'd........ NI................ M................. ........... ........... ........... ........... ...........
33030.............. Partial removal of heart .................. C................. ........... ........... ........... ........... ...........
sac.
33031.............. Partial removal of heart .................. C................. ........... ........... ........... ........... ...........
sac.
3303F.............. AJCC stage IA doc'd....... NI................ M................. ........... ........... ........... ........... ...........
3304F.............. AJCC stage IB doc'd....... NI................ M................. ........... ........... ........... ........... ...........
[[Page 67029]]
33050.............. Removal of heart sac .................. C................. ........... ........... ........... ........... ...........
lesion.
3305F.............. AJCC stage IC doc'd....... NI................ M................. ........... ........... ........... ........... ...........
3306F.............. AJCC stage IIA doc'd...... NI................ M................. ........... ........... ........... ........... ...........
3307F.............. AJCC stage IIB doc'd...... NI................ M................. ........... ........... ........... ........... ...........
3308F.............. AJCC stage IIC doc'd...... NI................ M................. ........... ........... ........... ........... ...........
3309F.............. AJCC stage IIIA doc'd..... NI................ M................. ........... ........... ........... ........... ...........
3310F.............. AJCC stage IIIB doc'd..... NI................ M................. ........... ........... ........... ........... ...........
3311F.............. AJCC stage IIIC doc'd..... NI................ M................. ........... ........... ........... ........... ...........
33120.............. Removal of heart lesion... .................. C................. ........... ........... ........... ........... ...........
3312F.............. AJCC stage IVA doc'd...... NI................ M................. ........... ........... ........... ........... ...........
33130.............. Removal of heart lesion... .................. C................. ........... ........... ........... ........... ...........
3313F.............. AJCC stage IVB doc'd...... NI................ M................. ........... ........... ........... ........... ...........
33140.............. Heart revascularize (tmr). .................. C................. ........... ........... ........... ........... ...........
33141.............. Heart tmr w/other .................. C................. ........... ........... ........... ........... ...........
procedure.
3314F.............. AJCC stage IVC doc'd...... NI................ M................. ........... ........... ........... ........... ...........
3315F.............. ER +or PR +breast cancer.. NI................ M................. ........... ........... ........... ........... ...........
3316F.............. ER- or PR- breast cancer.. NI................ M................. ........... ........... ........... ........... ...........
3317F.............. Path rpt malig cancer NI................ M................. ........... ........... ........... ........... ...........
doc'd.
3318F.............. Path rpt malig cancer NI................ M................. ........... ........... ........... ........... ...........
doc'd.
3319F.............. X-ray/CT/Ultrsnd et al NI................ M................. ........... ........... ........... ........... ...........
ord'd.
33202.............. Insert epicard eltrd, open .................. C................. ........... ........... ........... ........... ...........
33203.............. Insert epicard eltrd, endo .................. C................. ........... ........... ........... ........... ...........
33206.............. Insertion of heart .................. T................. 0089 121.6508 $7,748.43 $1,682.28 $1,549.69
pacemaker.
33207.............. Insertion of heart .................. T................. 0089 121.6508 $7,748.43 $1,682.28 $1,549.69
pacemaker.
33208.............. Insertion of heart .................. T................. 0655 140.0317 $8,919.18 ........... $1,783.84
pacemaker.
3320F.............. No Xray/CT/ et al ord'd... NI................ M................. ........... ........... ........... ........... ...........
33210.............. Insertion of heart .................. T................. 0106 69.5217 $4,428.12 ........... $885.62
electrode.
33211.............. Insertion of heart .................. T................. 0106 69.5217 $4,428.12 ........... $885.62
electrode.
33212.............. Insertion of pulse .................. T................. 0090 100.8341 $6,422.53 $1,612.80 $1,284.51
generator.
33213.............. Insertion of pulse .................. T................. 0654 109.2851 $6,960.81 ........... $1,392.16
generator.
33214.............. Upgrade of pacemaker .................. T................. 0655 140.0317 $8,919.18 ........... $1,783.84
system.
33215.............. Reposition pacing-defib .................. T................. 0105 23.9802 $1,527.39 ........... $305.48
lead.
33216.............. Insert lead pace-defib, .................. T................. 0106 69.5217 $4,428.12 ........... $885.62
one.
33217.............. Insert lead pace-defib, .................. T................. 0106 69.5217 $4,428.12 ........... $885.62
dual.
33218.............. Repair lead pace-defib, .................. T................. 0105 23.9802 $1,527.39 ........... $305.48
one.
33220.............. Repair lead pace-defib, .................. T................. 0105 23.9802 $1,527.39 ........... $305.48
dual.
33222.............. Revise pocket, pacemaker.. CH................ T................. 0136 15.0458 $958.33 ........... $191.67
33223.............. Revise pocket, pacing- CH................ T................. 0136 15.0458 $958.33 ........... $191.67
defib.
33224.............. Insert pacing lead & .................. T................. 0418 259.7486 $16,544.43 ........... $3,308.89
connect.
33225.............. L ventric pacing lead add- .................. T................. 0418 259.7486 $16,544.43 ........... $3,308.89
on.
33226.............. Reposition l ventric lead. .................. T................. 0105 23.9802 $1,527.39 ........... $305.48
33233.............. Removal of pacemaker .................. T................. 0105 23.9802 $1,527.39 ........... $305.48
system.
33234.............. Removal of pacemaker .................. T................. 0105 23.9802 $1,527.39 ........... $305.48
system.
33235.............. Removal pacemaker .................. T................. 0105 23.9802 $1,527.39 ........... $305.48
electrode.
33236.............. Remove electrode/ .................. C................. ........... ........... ........... ........... ...........
thoracotomy.
33237.............. Remove electrode/ .................. C................. ........... ........... ........... ........... ...........
thoracotomy.
33238.............. Remove electrode/ .................. C................. ........... ........... ........... ........... ...........
thoracotomy.
33240.............. Insert pulse generator.... CH................ T................. 0107 333.8096 $21,261.67 ........... $4,252.33
33241.............. Remove pulse generator.... .................. T................. 0105 23.9802 $1,527.39 ........... $305.48
33243.............. Remove eltrd/thoracotomy.. .................. C................. ........... ........... ........... ........... ...........
33244.............. Remove eltrd, transven.... .................. T................. 0105 23.9802 $1,527.39 ........... $305.48
33249.............. Eltrd/insert pace-defib... CH................ T................. 0108 404.8543 $25,786.79 ........... $5,157.36
33250.............. Ablate heart dysrhythm .................. C................. ........... ........... ........... ........... ...........
focus.
33251.............. Ablate heart dysrhythm .................. C................. ........... ........... ........... ........... ...........
focus.
33254.............. Ablate atria, lmtd........ .................. C................. ........... ........... ........... ........... ...........
33255.............. Ablate atria w/o bypass, .................. C................. ........... ........... ........... ........... ...........
ext.
33256.............. Ablate atria w/bypass, .................. C................. ........... ........... ........... ........... ...........
exten.
33257.............. Ablate atria, lmtd, add-on NI................ C................. ........... ........... ........... ........... ...........
33258.............. Ablate atria, x10sv, add- NI................ C................. ........... ........... ........... ........... ...........
on.
33259.............. Ablate atria w/bypass add- NI................ C................. ........... ........... ........... ........... ...........
on.
3325F.............. Preop asses 4 cataract NI................ M................. ........... ........... ........... ........... ...........
surg.
33261.............. Ablate heart dysrhythm .................. C................. ........... ........... ........... ........... ...........
focus.
33265.............. Ablate atria, lmtd, endo.. .................. C................. ........... ........... ........... ........... ...........
33266.............. Ablate atria, x10sv, endo. .................. C................. ........... ........... ........... ........... ...........
33282.............. Implant pat-active ht .................. S................. 0680 70.6073 $4,497.26 ........... $899.45
record.
33284.............. Remove pat-active ht CH................ T................. 0020 8.6850 $553.18 ........... $110.64
record.
33300.............. Repair of heart wound..... .................. C................. ........... ........... ........... ........... ...........
33305.............. Repair of heart wound..... .................. C................. ........... ........... ........... ........... ...........
33310.............. Exploratory heart surgery. .................. C................. ........... ........... ........... ........... ...........
33315.............. Exploratory heart surgery. .................. C................. ........... ........... ........... ........... ...........
33320.............. Repair major blood .................. C................. ........... ........... ........... ........... ...........
vessel(s).
33321.............. Repair major vessel....... .................. C................. ........... ........... ........... ........... ...........
33322.............. Repair major blood .................. C................. ........... ........... ........... ........... ...........
vessel(s).
33330.............. Insert major vessel graft. .................. C................. ........... ........... ........... ........... ...........
33332.............. Insert major vessel graft. .................. C................. ........... ........... ........... ........... ...........
33335.............. Insert major vessel graft. .................. C................. ........... ........... ........... ........... ...........
33400.............. Repair of aortic valve.... .................. C................. ........... ........... ........... ........... ...........
33401.............. Valvuloplasty, open....... .................. C................. ........... ........... ........... ........... ...........
33403.............. Valvuloplasty, w/cp bypass .................. C................. ........... ........... ........... ........... ...........
33404.............. Prepare heart-aorta .................. C................. ........... ........... ........... ........... ...........
conduit.
[[Page 67030]]
33405.............. Replacement of aortic .................. C................. ........... ........... ........... ........... ...........
valve.
33406.............. Replacement of aortic .................. C................. ........... ........... ........... ........... ...........
valve.
33410.............. Replacement of aortic .................. C................. ........... ........... ........... ........... ...........
valve.
33411.............. Replacement of aortic .................. C................. ........... ........... ........... ........... ...........
valve.
33412.............. Replacement of aortic .................. C................. ........... ........... ........... ........... ...........
valve.
33413.............. Replacement of aortic .................. C................. ........... ........... ........... ........... ...........
valve.
33414.............. Repair of aortic valve.... .................. C................. ........... ........... ........... ........... ...........
33415.............. Revision, subvalvular .................. C................. ........... ........... ........... ........... ...........
tissue.
33416.............. Revise ventricle muscle... .................. C................. ........... ........... ........... ........... ...........
33417.............. Repair of aortic valve.... .................. C................. ........... ........... ........... ........... ...........
33420.............. Revision of mitral valve.. .................. C................. ........... ........... ........... ........... ...........
33422.............. Revision of mitral valve.. .................. C................. ........... ........... ........... ........... ...........
33425.............. Repair of mitral valve.... .................. C................. ........... ........... ........... ........... ...........
33426.............. Repair of mitral valve.... .................. C................. ........... ........... ........... ........... ...........
33427.............. Repair of mitral valve.... .................. C................. ........... ........... ........... ........... ...........
33430.............. Replacement of mitral .................. C................. ........... ........... ........... ........... ...........
valve.
33460.............. Revision of tricuspid .................. C................. ........... ........... ........... ........... ...........
valve.
33463.............. Valvuloplasty, tricuspid.. .................. C................. ........... ........... ........... ........... ...........
33464.............. Valvuloplasty, tricuspid.. .................. C................. ........... ........... ........... ........... ...........
33465.............. Replace tricuspid valve... .................. C................. ........... ........... ........... ........... ...........
33468.............. Revision of tricuspid .................. C................. ........... ........... ........... ........... ...........
valve.
33470.............. Revision of pulmonary .................. C................. ........... ........... ........... ........... ...........
valve.
33471.............. Valvotomy, pulmonary valve .................. C................. ........... ........... ........... ........... ...........
33472.............. Revision of pulmonary .................. C................. ........... ........... ........... ........... ...........
valve.
33474.............. Revision of pulmonary .................. C................. ........... ........... ........... ........... ...........
valve.
33475.............. Replacement, pulmonary .................. C................. ........... ........... ........... ........... ...........
valve.
33476.............. Revision of heart chamber. .................. C................. ........... ........... ........... ........... ...........
33478.............. Revision of heart chamber. .................. C................. ........... ........... ........... ........... ...........
33496.............. Repair, prosth valve clot. .................. C................. ........... ........... ........... ........... ...........
33500.............. Repair heart vessel .................. C................. ........... ........... ........... ........... ...........
fistula.
33501.............. Repair heart vessel .................. C................. ........... ........... ........... ........... ...........
fistula.
33502.............. Coronary artery correction .................. C................. ........... ........... ........... ........... ...........
33503.............. Coronary artery graft..... .................. C................. ........... ........... ........... ........... ...........
33504.............. Coronary artery graft..... .................. C................. ........... ........... ........... ........... ...........
33505.............. Repair artery w/tunnel.... .................. C................. ........... ........... ........... ........... ...........
33506.............. Repair artery, .................. C................. ........... ........... ........... ........... ...........
translocation.
33507.............. Repair art, intramural.... .................. C................. ........... ........... ........... ........... ...........
33508.............. Endoscopic vein harvest... .................. N................. ........... ........... ........... ........... ...........
33510.............. CABG, vein, single........ .................. C................. ........... ........... ........... ........... ...........
33511.............. CABG, vein, two........... .................. C................. ........... ........... ........... ........... ...........
33512.............. CABG, vein, three......... .................. C................. ........... ........... ........... ........... ...........
33513.............. CABG, vein, four.......... .................. C................. ........... ........... ........... ........... ...........
33514.............. CABG, vein, five.......... .................. C................. ........... ........... ........... ........... ...........
33516.............. Cabg, vein, six or more... .................. C................. ........... ........... ........... ........... ...........
33517.............. CABG, artery-vein, single. .................. C................. ........... ........... ........... ........... ...........
33518.............. CABG, artery-vein, two.... .................. C................. ........... ........... ........... ........... ...........
33519.............. CABG, artery-vein, three.. .................. C................. ........... ........... ........... ........... ...........
33521.............. CABG, artery-vein, four... .................. C................. ........... ........... ........... ........... ...........
33522.............. CABG, artery-vein, five... .................. C................. ........... ........... ........... ........... ...........
33523.............. Cabg, art-vein, six or .................. C................. ........... ........... ........... ........... ...........
more.
33530.............. Coronary artery, bypass/ .................. C................. ........... ........... ........... ........... ...........
reop.
33533.............. CABG, arterial, single.... .................. C................. ........... ........... ........... ........... ...........
33534.............. CABG, arterial, two....... .................. C................. ........... ........... ........... ........... ...........
33535.............. CABG, arterial, three..... .................. C................. ........... ........... ........... ........... ...........
33536.............. Cabg, arterial, four or .................. C................. ........... ........... ........... ........... ...........
more.
33542.............. Removal of heart lesion... .................. C................. ........... ........... ........... ........... ...........
33545.............. Repair of heart damage.... .................. C................. ........... ........... ........... ........... ...........
33548.............. Restore/remodel, ventricle .................. C................. ........... ........... ........... ........... ...........
33572.............. Open coronary .................. C................. ........... ........... ........... ........... ...........
endarterectomy.
33600.............. Closure of valve.......... .................. C................. ........... ........... ........... ........... ...........
33602.............. Closure of valve.......... .................. C................. ........... ........... ........... ........... ...........
33606.............. Anastomosis/artery-aorta.. .................. C................. ........... ........... ........... ........... ...........
33608.............. Repair anomaly w/conduit.. .................. C................. ........... ........... ........... ........... ...........
33610.............. Repair by enlargement..... .................. C................. ........... ........... ........... ........... ...........
33611.............. Repair double ventricle... .................. C................. ........... ........... ........... ........... ...........
33612.............. Repair double ventricle... .................. C................. ........... ........... ........... ........... ...........
33615.............. Repair, modified fontan... .................. C................. ........... ........... ........... ........... ...........
33617.............. Repair single ventricle... .................. C................. ........... ........... ........... ........... ...........
33619.............. Repair single ventricle... .................. C................. ........... ........... ........... ........... ...........
33641.............. Repair heart septum defect .................. C................. ........... ........... ........... ........... ...........
33645.............. Revision of heart veins... .................. C................. ........... ........... ........... ........... ...........
33647.............. Repair heart septum .................. C................. ........... ........... ........... ........... ...........
defects.
33660.............. Repair of heart defects... .................. C................. ........... ........... ........... ........... ...........
33665.............. Repair of heart defects... .................. C................. ........... ........... ........... ........... ...........
33670.............. Repair of heart chambers.. .................. C................. ........... ........... ........... ........... ...........
33675.............. Close mult vsd............ .................. C................. ........... ........... ........... ........... ...........
33676.............. Close mult vsd w/resection .................. C................. ........... ........... ........... ........... ...........
33677.............. Cl mult vsd w/rem pul band .................. C................. ........... ........... ........... ........... ...........
33681.............. Repair heart septum defect .................. C................. ........... ........... ........... ........... ...........
33684.............. Repair heart septum defect .................. C................. ........... ........... ........... ........... ...........
[[Page 67031]]
33688.............. Repair heart septum defect .................. C................. ........... ........... ........... ........... ...........
33690.............. Reinforce pulmonary artery .................. C................. ........... ........... ........... ........... ...........
33692.............. Repair of heart defects... .................. C................. ........... ........... ........... ........... ...........
33694.............. Repair of heart defects... .................. C................. ........... ........... ........... ........... ...........
33697.............. Repair of heart defects... .................. C................. ........... ........... ........... ........... ...........
33702.............. Repair of heart defects... .................. C................. ........... ........... ........... ........... ...........
33710.............. Repair of heart defects... .................. C................. ........... ........... ........... ........... ...........
33720.............. Repair of heart defect.... .................. C................. ........... ........... ........... ........... ...........
33722.............. Repair of heart defect.... .................. C................. ........... ........... ........... ........... ...........
33724.............. Repair venous anomaly..... .................. C................. ........... ........... ........... ........... ...........
33726.............. Repair pul venous stenosis .................. C................. ........... ........... ........... ........... ...........
33730.............. Repair heart-vein .................. C................. ........... ........... ........... ........... ...........
defect(s).
33732.............. Repair heart-vein defect.. .................. C................. ........... ........... ........... ........... ...........
33735.............. Revision of heart chamber. .................. C................. ........... ........... ........... ........... ...........
33736.............. Revision of heart chamber. .................. C................. ........... ........... ........... ........... ...........
33737.............. Revision of heart chamber. .................. C................. ........... ........... ........... ........... ...........
33750.............. Major vessel shunt........ .................. C................. ........... ........... ........... ........... ...........
33755.............. Major vessel shunt........ .................. C................. ........... ........... ........... ........... ...........
33762.............. Major vessel shunt........ .................. C................. ........... ........... ........... ........... ...........
33764.............. Major vessel shunt & graft .................. C................. ........... ........... ........... ........... ...........
33766.............. Major vessel shunt........ .................. C................. ........... ........... ........... ........... ...........
33767.............. Major vessel shunt........ .................. C................. ........... ........... ........... ........... ...........
33768.............. Cavopulmonary shunting.... .................. C................. ........... ........... ........... ........... ...........
33770.............. Repair great vessels .................. C................. ........... ........... ........... ........... ...........
defect.
33771.............. Repair great vessels .................. C................. ........... ........... ........... ........... ...........
defect.
33774.............. Repair great vessels .................. C................. ........... ........... ........... ........... ...........
defect.
33775.............. Repair great vessels .................. C................. ........... ........... ........... ........... ...........
defect.
33776.............. Repair great vessels .................. C................. ........... ........... ........... ........... ...........
defect.
33777.............. Repair great vessels .................. C................. ........... ........... ........... ........... ...........
defect.
33778.............. Repair great vessels .................. C................. ........... ........... ........... ........... ...........
defect.
33779.............. Repair great vessels .................. C................. ........... ........... ........... ........... ...........
defect.
33780.............. Repair great vessels .................. C................. ........... ........... ........... ........... ...........
defect.
33781.............. Repair great vessels .................. C................. ........... ........... ........... ........... ...........
defect.
33786.............. Repair arterial trunk..... .................. C................. ........... ........... ........... ........... ...........
33788.............. Revision of pulmonary .................. C................. ........... ........... ........... ........... ...........
artery.
33800.............. Aortic suspension......... .................. C................. ........... ........... ........... ........... ...........
33802.............. Repair vessel defect...... .................. C................. ........... ........... ........... ........... ...........
33803.............. Repair vessel defect...... .................. C................. ........... ........... ........... ........... ...........
33813.............. Repair septal defect...... .................. C................. ........... ........... ........... ........... ...........
33814.............. Repair septal defect...... .................. C................. ........... ........... ........... ........... ...........
33820.............. Revise major vessel....... .................. C................. ........... ........... ........... ........... ...........
33822.............. Revise major vessel....... .................. C................. ........... ........... ........... ........... ...........
33824.............. Revise major vessel....... .................. C................. ........... ........... ........... ........... ...........
33840.............. Remove aorta constriction. .................. C................. ........... ........... ........... ........... ...........
33845.............. Remove aorta constriction. .................. C................. ........... ........... ........... ........... ...........
33851.............. Remove aorta constriction. .................. C................. ........... ........... ........... ........... ...........
33852.............. Repair septal defect...... .................. C................. ........... ........... ........... ........... ...........
33853.............. Repair septal defect...... .................. C................. ........... ........... ........... ........... ...........
33860.............. Ascending aortic graft.... .................. C................. ........... ........... ........... ........... ...........
33861.............. Ascending aortic graft.... .................. C................. ........... ........... ........... ........... ...........
33863.............. Ascending aortic graft.... .................. C................. ........... ........... ........... ........... ...........
33864.............. Ascending aortic graft.... NI................ C................. ........... ........... ........... ........... ...........
33870.............. Transverse aortic arch .................. C................. ........... ........... ........... ........... ...........
graft.
33875.............. Thoracic aortic graft..... .................. C................. ........... ........... ........... ........... ...........
33877.............. Thoracoabdominal graft.... .................. C................. ........... ........... ........... ........... ...........
33880.............. Endovasc taa repr incl .................. C................. ........... ........... ........... ........... ...........
subcl.
33881.............. Endovasc taa repr w/o .................. C................. ........... ........... ........... ........... ...........
subcl.
33883.............. Insert endovasc prosth, .................. C................. ........... ........... ........... ........... ...........
taa.
33884.............. Endovasc prosth, taa, add- .................. C................. ........... ........... ........... ........... ...........
on.
33886.............. Endovasc prosth, delayed.. .................. C................. ........... ........... ........... ........... ...........
33889.............. Artery transpose/endovas .................. C................. ........... ........... ........... ........... ...........
taa.
33891.............. Car-car bp grft/endovas .................. C................. ........... ........... ........... ........... ...........
taa.
33910.............. Remove lung artery emboli. .................. C................. ........... ........... ........... ........... ...........
33915.............. Remove lung artery emboli. .................. C................. ........... ........... ........... ........... ...........
33916.............. Surgery of great vessel... .................. C................. ........... ........... ........... ........... ...........
33917.............. Repair pulmonary artery... .................. C................. ........... ........... ........... ........... ...........
33920.............. Repair pulmonary atresia.. .................. C................. ........... ........... ........... ........... ...........
33922.............. Transect pulmonary artery. .................. C................. ........... ........... ........... ........... ...........
33924.............. Remove pulmonary shunt.... .................. C................. ........... ........... ........... ........... ...........
33925.............. Rpr pul art unifocal w/o .................. C................. ........... ........... ........... ........... ...........
cpb.
33926.............. Repr pul art, unifocal w/ .................. C................. ........... ........... ........... ........... ...........
cpb.
33930.............. Removal of donor heart/ .................. C................. ........... ........... ........... ........... ...........
lung.
33933.............. Prepare donor heart/lung.. .................. C................. ........... ........... ........... ........... ...........
33935.............. Transplantation, heart/ .................. C................. ........... ........... ........... ........... ...........
lung.
33940.............. Removal of donor heart.... .................. C................. ........... ........... ........... ........... ...........
33944.............. Prepare donor heart....... .................. C................. ........... ........... ........... ........... ...........
33945.............. Transplantation of heart.. .................. C................. ........... ........... ........... ........... ...........
33960.............. External circulation .................. C................. ........... ........... ........... ........... ...........
assist.
33961.............. External circulation .................. C................. ........... ........... ........... ........... ...........
assist.
33967.............. Insert ia percut device... .................. C................. ........... ........... ........... ........... ...........
[[Page 67032]]
33968.............. Remove aortic assist .................. C................. ........... ........... ........... ........... ...........
device.
33970.............. Aortic circulation assist. .................. C................. ........... ........... ........... ........... ...........
33971.............. Aortic circulation assist. .................. C................. ........... ........... ........... ........... ...........
33973.............. Insert balloon device..... .................. C................. ........... ........... ........... ........... ...........
33974.............. Remove intra-aortic .................. C................. ........... ........... ........... ........... ...........
balloon.
33975.............. Implant ventricular device .................. C................. ........... ........... ........... ........... ...........
33976.............. Implant ventricular device .................. C................. ........... ........... ........... ........... ...........
33977.............. Remove ventricular device. .................. C................. ........... ........... ........... ........... ...........
33978.............. Remove ventricular device. .................. C................. ........... ........... ........... ........... ...........
33979.............. Insert intracorporeal .................. C................. ........... ........... ........... ........... ...........
device.
33980.............. Remove intracorporeal .................. C................. ........... ........... ........... ........... ...........
device.
33999.............. Cardiac surgery procedure. .................. T................. 0070 5.2024 $331.36 ........... $66.27
34001.............. Removal of artery clot.... .................. C................. ........... ........... ........... ........... ...........
34051.............. Removal of artery clot.... .................. C................. ........... ........... ........... ........... ...........
34101.............. Removal of artery clot.... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
34111.............. Removal of arm artery clot .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
34151.............. Removal of artery clot.... .................. C................. ........... ........... ........... ........... ...........
34201.............. Removal of artery clot.... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
34203.............. Removal of leg artery clot .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
34401.............. Removal of vein clot...... .................. C................. ........... ........... ........... ........... ...........
34421.............. Removal of vein clot...... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
34451.............. Removal of vein clot...... .................. C................. ........... ........... ........... ........... ...........
34471.............. Removal of vein clot...... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
34490.............. Removal of vein clot...... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
34501.............. Repair valve, femoral vein .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
34502.............. Reconstruct vena cava..... .................. C................. ........... ........... ........... ........... ...........
34510.............. Transposition of vein .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
valve.
34520.............. Cross-over vein graft..... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
34530.............. Leg vein fusion........... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
34800.............. Endovas aaa repr w/sm tube .................. C................. ........... ........... ........... ........... ...........
34802.............. Endovas aaa repr w/2-p .................. C................. ........... ........... ........... ........... ...........
part.
34803.............. Endovas aaa repr w/3-p .................. C................. ........... ........... ........... ........... ...........
part.
34804.............. Endovas aaa repr w/1-p .................. C................. ........... ........... ........... ........... ...........
part.
34805.............. Endovas aaa repr w/long .................. C................. ........... ........... ........... ........... ...........
tube.
34806.............. Aneurysm press sensor add- NI................ C................. ........... ........... ........... ........... ...........
on.
34808.............. Endovas iliac a device .................. C................. ........... ........... ........... ........... ...........
addon.
34812.............. Xpose for endoprosth, .................. C................. ........... ........... ........... ........... ...........
femorl.
34813.............. Femoral endovas graft add- .................. C................. ........... ........... ........... ........... ...........
on.
34820.............. Xpose for endoprosth, .................. C................. ........... ........... ........... ........... ...........
iliac.
34825.............. Endovasc extend prosth, .................. C................. ........... ........... ........... ........... ...........
init.
34826.............. Endovasc exten prosth, .................. C................. ........... ........... ........... ........... ...........
add'l.
34830.............. Open aortic tube prosth .................. C................. ........... ........... ........... ........... ...........
repr.
34831.............. Open aortoiliac prosth .................. C................. ........... ........... ........... ........... ...........
repr.
34832.............. Open aortofemor prosth .................. C................. ........... ........... ........... ........... ...........
repr.
34833.............. Xpose for endoprosth, .................. C................. ........... ........... ........... ........... ...........
iliac.
34834.............. Xpose, endoprosth, .................. C................. ........... ........... ........... ........... ...........
brachial.
34900.............. Endovasc iliac repr w/ .................. C................. ........... ........... ........... ........... ...........
graft.
35001.............. Repair defect of artery... .................. C................. ........... ........... ........... ........... ...........
35002.............. Repair artery rupture, .................. C................. ........... ........... ........... ........... ...........
neck.
35005.............. Repair defect of artery... .................. C................. ........... ........... ........... ........... ...........
35011.............. Repair defect of artery... .................. T................. 0653 40.4667 $2,577.49 ........... $515.50
35013.............. Repair artery rupture, arm .................. C................. ........... ........... ........... ........... ...........
35021.............. Repair defect of artery... .................. C................. ........... ........... ........... ........... ...........
35022.............. Repair artery rupture, .................. C................. ........... ........... ........... ........... ...........
chest.
35045.............. Repair defect of arm .................. C................. ........... ........... ........... ........... ...........
artery.
35081.............. Repair defect of artery... .................. C................. ........... ........... ........... ........... ...........
35082.............. Repair artery rupture, .................. C................. ........... ........... ........... ........... ...........
aorta.
35091.............. Repair defect of artery... .................. C................. ........... ........... ........... ........... ...........
35092.............. Repair artery rupture, .................. C................. ........... ........... ........... ........... ...........
aorta.
35102.............. Repair defect of artery... .................. C................. ........... ........... ........... ........... ...........
35103.............. Repair artery rupture, .................. C................. ........... ........... ........... ........... ...........
groin.
35111.............. Repair defect of artery... .................. C................. ........... ........... ........... ........... ...........
35112.............. Repair artery .................. C................. ........... ........... ........... ........... ...........
rupture,spleen.
35121.............. Repair defect of artery... .................. C................. ........... ........... ........... ........... ...........
35122.............. Repair artery rupture, .................. C................. ........... ........... ........... ........... ...........
belly.
35131.............. Repair defect of artery... .................. C................. ........... ........... ........... ........... ...........
35132.............. Repair artery rupture, .................. C................. ........... ........... ........... ........... ...........
groin.
35141.............. Repair defect of artery... .................. C................. ........... ........... ........... ........... ...........
35142.............. Repair artery rupture, .................. C................. ........... ........... ........... ........... ...........
thigh.
35151.............. Repair defect of artery... .................. C................. ........... ........... ........... ........... ...........
35152.............. Repair artery rupture, .................. C................. ........... ........... ........... ........... ...........
knee.
35180.............. Repair blood vessel lesion .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35182.............. Repair blood vessel lesion .................. C................. ........... ........... ........... ........... ...........
35184.............. Repair blood vessel lesion .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35188.............. Repair blood vessel lesion .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
35189.............. Repair blood vessel lesion .................. C................. ........... ........... ........... ........... ...........
35190.............. Repair blood vessel lesion .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35201.............. Repair blood vessel lesion .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35206.............. Repair blood vessel lesion .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35207.............. Repair blood vessel lesion .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
[[Page 67033]]
35211.............. Repair blood vessel lesion .................. C................. ........... ........... ........... ........... ...........
35216.............. Repair blood vessel lesion .................. C................. ........... ........... ........... ........... ...........
35221.............. Repair blood vessel lesion .................. C................. ........... ........... ........... ........... ...........
35226.............. Repair blood vessel lesion .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35231.............. Repair blood vessel lesion .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35236.............. Repair blood vessel lesion .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35241.............. Repair blood vessel lesion .................. C................. ........... ........... ........... ........... ...........
35246.............. Repair blood vessel lesion .................. C................. ........... ........... ........... ........... ...........
35251.............. Repair blood vessel lesion .................. C................. ........... ........... ........... ........... ...........
35256.............. Repair blood vessel lesion .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35261.............. Repair blood vessel lesion .................. T................. 0653 40.4667 $2,577.49 ........... $515.50
35266.............. Repair blood vessel lesion .................. T................. 0653 40.4667 $2,577.49 ........... $515.50
35271.............. Repair blood vessel lesion .................. C................. ........... ........... ........... ........... ...........
35276.............. Repair blood vessel lesion .................. C................. ........... ........... ........... ........... ...........
35281.............. Repair blood vessel lesion .................. C................. ........... ........... ........... ........... ...........
35286.............. Repair blood vessel lesion .................. T................. 0653 40.4667 $2,577.49 ........... $515.50
35301.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35302.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35303.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35304.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35305.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35306.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35311.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35321.............. Rechanneling of artery.... .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35331.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35341.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35351.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35355.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35361.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35363.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35371.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35372.............. Rechanneling of artery.... .................. C................. ........... ........... ........... ........... ...........
35390.............. Reoperation, carotid add- .................. C................. ........... ........... ........... ........... ...........
on.
35400.............. Angioscopy................ .................. C................. ........... ........... ........... ........... ...........
35450.............. Repair arterial blockage.. .................. C................. ........... ........... ........... ........... ...........
35452.............. Repair arterial blockage.. .................. C................. ........... ........... ........... ........... ...........
35454.............. Repair arterial blockage.. .................. C................. ........... ........... ........... ........... ...........
35456.............. Repair arterial blockage.. .................. C................. ........... ........... ........... ........... ...........
35458.............. Repair arterial blockage.. CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
35459.............. Repair arterial blockage.. CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
35460.............. Repair venous blockage.... CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
35470.............. Repair arterial blockage.. CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
35471.............. Repair arterial blockage.. CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
35472.............. Repair arterial blockage.. CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
35473.............. Repair arterial blockage.. CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
35474.............. Repair arterial blockage.. CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
35475.............. Repair arterial blockage.. CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
35476.............. Repair venous blockage.... CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
35480.............. Atherectomy, open......... .................. C................. ........... ........... ........... ........... ...........
35481.............. Atherectomy, open......... .................. C................. ........... ........... ........... ........... ...........
35482.............. Atherectomy, open......... .................. C................. ........... ........... ........... ........... ...........
35483.............. Atherectomy, open......... .................. C................. ........... ........... ........... ........... ...........
35484.............. Atherectomy, open......... CH................ T................. 0082 87.5137 $5,574.10 ........... $1,114.82
35485.............. Atherectomy, open......... CH................ T................. 0082 87.5137 $5,574.10 ........... $1,114.82
35490.............. Atherectomy, percutaneous. CH................ T................. 0082 87.5137 $5,574.10 ........... $1,114.82
35491.............. Atherectomy, percutaneous. CH................ T................. 0082 87.5137 $5,574.10 ........... $1,114.82
35492.............. Atherectomy, percutaneous. CH................ T................. 0082 87.5137 $5,574.10 ........... $1,114.82
35493.............. Atherectomy, percutaneous. CH................ T................. 0082 87.5137 $5,574.10 ........... $1,114.82
35494.............. Atherectomy, percutaneous. CH................ T................. 0082 87.5137 $5,574.10 ........... $1,114.82
35495.............. Atherectomy, percutaneous. CH................ T................. 0082 87.5137 $5,574.10 ........... $1,114.82
35500.............. Harvest vein for bypass... CH................ T................. 0103 14.6576 $933.60 ........... $186.72
35501.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35506.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35508.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35509.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35510.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35511.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35512.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35515.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35516.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35518.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35521.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35522.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35523.............. Artery bypass graft....... NI................ C................. ........... ........... ........... ........... ...........
35525.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35526.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35531.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35533.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35536.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35537.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
[[Page 67034]]
35538.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35539.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35540.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35548.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35549.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35551.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35556.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35558.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35560.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35563.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35565.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35566.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35571.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35572.............. Harvest femoropopliteal .................. N................. ........... ........... ........... ........... ...........
vein.
35583.............. Vein bypass graft......... .................. C................. ........... ........... ........... ........... ...........
35585.............. Vein bypass graft......... .................. C................. ........... ........... ........... ........... ...........
35587.............. Vein bypass graft......... .................. C................. ........... ........... ........... ........... ...........
35600.............. Harvest art for cabg add- .................. C................. ........... ........... ........... ........... ...........
on.
35601.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35606.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35612.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35616.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35621.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35623.............. Bypass graft, not vein.... .................. C................. ........... ........... ........... ........... ...........
35626.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35631.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35636.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35637.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35638.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35642.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35645.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35646.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35647.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35650.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35651.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35654.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35656.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35661.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35663.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35665.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35666.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35671.............. Artery bypass graft....... .................. C................. ........... ........... ........... ........... ...........
35681.............. Composite bypass graft.... .................. C................. ........... ........... ........... ........... ...........
35682.............. Composite bypass graft.... .................. C................. ........... ........... ........... ........... ...........
35683.............. Composite bypass graft.... .................. C................. ........... ........... ........... ........... ...........
35685.............. Bypass graft patency/patch .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35686.............. Bypass graft/av fist .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
patency.
35691.............. Arterial transposition.... .................. C................. ........... ........... ........... ........... ...........
35693.............. Arterial transposition.... .................. C................. ........... ........... ........... ........... ...........
35694.............. Arterial transposition.... .................. C................. ........... ........... ........... ........... ...........
35695.............. Arterial transposition.... .................. C................. ........... ........... ........... ........... ...........
35697.............. Reimplant artery each..... .................. C................. ........... ........... ........... ........... ...........
35700.............. Reoperation, bypass graft. .................. C................. ........... ........... ........... ........... ...........
35701.............. Exploration, carotid .................. C................. ........... ........... ........... ........... ...........
artery.
35721.............. Exploration, femoral .................. C................. ........... ........... ........... ........... ...........
artery.
35741.............. Exploration popliteal .................. C................. ........... ........... ........... ........... ...........
artery.
35761.............. Exploration of artery/vein .................. T................. 0115 29.6965 $1,891.49 ........... $378.30
35800.............. Explore neck vessels...... .................. C................. ........... ........... ........... ........... ...........
35820.............. Explore chest vessels..... .................. C................. ........... ........... ........... ........... ...........
35840.............. Explore abdominal vessels. .................. C................. ........... ........... ........... ........... ...........
35860.............. Explore limb vessels...... .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
35870.............. Repair vessel graft defect .................. C................. ........... ........... ........... ........... ...........
35875.............. Removal of clot in graft.. .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
35876.............. Removal of clot in graft.. .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
35879.............. Revise graft w/vein....... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
35881.............. Revise graft w/vein....... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
35883.............. Revise graft w/nonauto .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
graft.
35884.............. Revise graft w/vein....... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
35901.............. Excision, graft, neck..... .................. C................. ........... ........... ........... ........... ...........
35903.............. Excision, graft, extremity .................. T................. 0115 29.6965 $1,891.49 ........... $378.30
35905.............. Excision, graft, thorax... .................. C................. ........... ........... ........... ........... ...........
35907.............. Excision, graft, abdomen.. .................. C................. ........... ........... ........... ........... ...........
36000.............. Place needle in vein...... .................. N................. ........... ........... ........... ........... ...........
36002.............. Pseudoaneurysm injection .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
trt.
36005.............. Injection ext venography.. .................. N................. ........... ........... ........... ........... ...........
36010.............. Place catheter in vein.... .................. N................. ........... ........... ........... ........... ...........
36011.............. Place catheter in vein.... .................. N................. ........... ........... ........... ........... ...........
36012.............. Place catheter in vein.... .................. N................. ........... ........... ........... ........... ...........
36013.............. Place catheter in artery.. .................. N................. ........... ........... ........... ........... ...........
36014.............. Place catheter in artery.. .................. N................. ........... ........... ........... ........... ...........
[[Page 67035]]
36015.............. Place catheter in artery.. .................. N................. ........... ........... ........... ........... ...........
36100.............. Establish access to artery .................. N................. ........... ........... ........... ........... ...........
36120.............. Establish access to artery .................. N................. ........... ........... ........... ........... ...........
36140.............. Establish access to artery .................. N................. ........... ........... ........... ........... ...........
36145.............. Artery to vein shunt...... .................. N................. ........... ........... ........... ........... ...........
36160.............. Establish access to aorta. .................. N................. ........... ........... ........... ........... ...........
36200.............. Place catheter in aorta... .................. N................. ........... ........... ........... ........... ...........
36215.............. Place catheter in artery.. .................. N................. ........... ........... ........... ........... ...........
36216.............. Place catheter in artery.. .................. N................. ........... ........... ........... ........... ...........
36217.............. Place catheter in artery.. .................. N................. ........... ........... ........... ........... ...........
36218.............. Place catheter in artery.. .................. N................. ........... ........... ........... ........... ...........
36245.............. Place catheter in artery.. .................. N................. ........... ........... ........... ........... ...........
36246.............. Place catheter in artery.. .................. N................. ........... ........... ........... ........... ...........
36247.............. Place catheter in artery.. .................. N................. ........... ........... ........... ........... ...........
36248.............. Place catheter in artery.. .................. N................. ........... ........... ........... ........... ...........
36260.............. Insertion of infusion pump .................. T................. 0623 28.8743 $1,839.12 ........... $367.82
36261.............. Revision of infusion pump. CH................ T................. 0105 23.9802 $1,527.39 ........... $305.48
36262.............. Removal of infusion pump.. CH................ T................. 0105 23.9802 $1,527.39 ........... $305.48
36299.............. Vessel injection procedure .................. N................. ........... ........... ........... ........... ...........
36400.............. Bl draw < 3 yrs fem/ .................. N................. ........... ........... ........... ........... ...........
jugular.
36405.............. Bl draw < 3 yrs scalp vein .................. N................. ........... ........... ........... ........... ...........
36406.............. Bl draw < 3 yrs other vein .................. N................. ........... ........... ........... ........... ...........
36410.............. Non-routine bl draw > 3 .................. N................. ........... ........... ........... ........... ...........
yrs.
36415.............. Routine venipuncture...... .................. A................. ........... ........... ........... ........... ...........
36416.............. Capillary blood draw...... .................. N................. ........... ........... ........... ........... ...........
36420.............. Vein access cutdown < 1 yr .................. T................. 0035 0.2143 $13.65 ........... $2.73
36425.............. Vein access cutdown > 1 yr .................. T................. 0035 0.2143 $13.65 ........... $2.73
36430.............. Blood transfusion service. .................. S................. 0110 3.3967 $216.35 ........... $43.27
36440.............. Bl push transfuse, 2 yr or .................. S................. 0110 3.3967 $216.35 ........... $43.27
<.
36450.............. Bl exchange/transfuse, nb. .................. S................. 0110 3.3967 $216.35 ........... $43.27
36455.............. Bl exchange/transfuse non- .................. S................. 0110 3.3967 $216.35 ........... $43.27
nb.
36460.............. Transfusion service, fetal .................. S................. 0110 3.3967 $216.35 ........... $43.27
36468.............. Injection(s), spider veins CH................ T................. 0013 0.7930 $50.51 ........... $10.10
36469.............. Injection(s), spider veins CH................ T................. 0013 0.7930 $50.51 ........... $10.10
36470.............. Injection therapy of vein. CH................ T................. 0013 0.7930 $50.51 ........... $10.10
36471.............. Injection therapy of veins CH................ T................. 0013 0.7930 $50.51 ........... $10.10
36475.............. Endovenous rf, 1st vein... .................. T................. 0091 42.6114 $2,714.09 ........... $542.82
36476.............. Endovenous rf, vein add-on CH................ T................. 0092 25.8410 $1,645.92 ........... $329.18
36478.............. Endovenous laser, 1st vein .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
36479.............. Endovenous laser vein add- .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
on.
36481.............. Insertion of catheter, .................. N................. ........... ........... ........... ........... ...........
vein.
36500.............. Insertion of catheter, .................. N................. ........... ........... ........... ........... ...........
vein.
36510.............. Insertion of catheter, .................. N................. ........... ........... ........... ........... ...........
vein.
36511.............. Apheresis wbc............. .................. S................. 0111 11.5058 $732.85 $198.40 $146.57
36512.............. Apheresis rbc............. .................. S................. 0111 11.5058 $732.85 $198.40 $146.57
36513.............. Apheresis platelets....... .................. S................. 0111 11.5058 $732.85 $198.40 $146.57
36514.............. Apheresis plasma.......... .................. S................. 0111 11.5058 $732.85 $198.40 $146.57
36515.............. Apheresis, adsorp/reinfuse .................. S................. 0112 30.6035 $1,949.26 $433.29 $389.85
36516.............. Apheresis, selective...... .................. S................. 0112 30.6035 $1,949.26 $433.29 $389.85
36522.............. Photopheresis............. .................. S................. 0112 30.6035 $1,949.26 $433.29 $389.85
36540.............. Collect blood venous CH................ D................. ........... ........... ........... ........... ...........
device.
36550.............. Declot vascular device.... CH................ D................. ........... ........... ........... ........... ...........
36555.............. Insert non-tunnel cv cath. .................. T................. 0621 10.9092 $694.85 ........... $138.97
36556.............. Insert non-tunnel cv cath. .................. T................. 0621 10.9092 $694.85 ........... $138.97
36557.............. Insert tunneled cv cath... .................. T................. 0622 24.1069 $1,535.46 ........... $307.09
36558.............. Insert tunneled cv cath... .................. T................. 0622 24.1069 $1,535.46 ........... $307.09
36560.............. Insert tunneled cv cath... .................. T................. 0623 28.8743 $1,839.12 ........... $367.82
36561.............. Insert tunneled cv cath... .................. T................. 0623 28.8743 $1,839.12 ........... $367.82
36563.............. Insert tunneled cv cath... .................. T................. 0623 28.8743 $1,839.12 ........... $367.82
36565.............. Insert tunneled cv cath... .................. T................. 0623 28.8743 $1,839.12 ........... $367.82
36566.............. Insert tunneled cv cath... .................. T................. 0625 81.7482 $5,206.87 ........... $1,041.37
36568.............. Insert picc cath.......... .................. T................. 0621 10.9092 $694.85 ........... $138.97
36569.............. Insert picc cath.......... .................. T................. 0621 10.9092 $694.85 ........... $138.97
36570.............. Insert picvad cath........ .................. T................. 0622 24.1069 $1,535.46 ........... $307.09
36571.............. Insert picvad cath........ .................. T................. 0622 24.1069 $1,535.46 ........... $307.09
36575.............. Repair tunneled cv cath... CH................ T................. 0109 5.6614 $360.60 ........... $72.12
36576.............. Repair tunneled cv cath... .................. T................. 0621 10.9092 $694.85 ........... $138.97
36578.............. Replace tunneled cv cath.. .................. T................. 0622 24.1069 $1,535.46 ........... $307.09
36580.............. Replace cvad cath......... .................. T................. 0621 10.9092 $694.85 ........... $138.97
36581.............. Replace tunneled cv cath.. .................. T................. 0622 24.1069 $1,535.46 ........... $307.09
36582.............. Replace tunneled cv cath.. .................. T................. 0623 28.8743 $1,839.12 ........... $367.82
36583.............. Replace tunneled cv cath.. .................. T................. 0623 28.8743 $1,839.12 ........... $367.82
36584.............. Replace picc cath......... .................. T................. 0621 10.9092 $694.85 ........... $138.97
36585.............. Replace picvad cath....... .................. T................. 0622 24.1069 $1,535.46 ........... $307.09
36589.............. Removal tunneled cv cath.. CH................ T................. 0109 5.6614 $360.60 ........... $72.12
36590.............. Removal tunneled cv cath.. .................. T................. 0621 10.9092 $694.85 ........... $138.97
36591.............. Draw blood off venous NI................ Q................. 0624 0.5689 $36.24 $12.65 $7.25
device.
36592.............. Collect blood from picc... NI................ N................. ........... ........... ........... ........... ...........
36593.............. Declot vascular device.... NI................ T................. 0676 2.4824 $158.11 ........... $31.62
36595.............. Mech remov tunneled cv .................. T................. 0622 24.1069 $1,535.46 ........... $307.09
cath.
[[Page 67036]]
36596.............. Mech remov tunneled cv .................. T................. 0621 10.9092 $694.85 ........... $138.97
cath.
36597.............. Reposition venous catheter .................. T................. 0621 10.9092 $694.85 ........... $138.97
36598.............. Inj w/fluor, eval cv CH................ T................. 0676 2.4824 $158.11 ........... $31.62
device.
36600.............. Withdrawal of arterial .................. Q................. 0035 0.2143 $13.65 ........... $2.73
blood.
36620.............. Insertion catheter, artery .................. N................. ........... ........... ........... ........... ...........
36625.............. Insertion catheter, artery .................. N................. ........... ........... ........... ........... ...........
36640.............. Insertion catheter, artery .................. T................. 0623 28.8743 $1,839.12 ........... $367.82
36660.............. Insertion catheter, artery .................. C................. ........... ........... ........... ........... ...........
36680.............. Insert needle, bone cavity .................. T................. 0002 1.1097 $70.68 ........... $14.14
36800.............. Insertion of cannula...... .................. T................. 0115 29.6965 $1,891.49 ........... $378.30
36810.............. Insertion of cannula...... .................. T................. 0115 29.6965 $1,891.49 ........... $378.30
36815.............. Insertion of cannula...... .................. T................. 0115 29.6965 $1,891.49 ........... $378.30
36818.............. Av fuse, uppr arm, .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
cephalic.
36819.............. Av fuse, uppr arm, basilic .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
36820.............. Av fusion/forearm vein.... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
36821.............. Av fusion direct any site. .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
36822.............. Insertion of cannula(s)... .................. C................. ........... ........... ........... ........... ...........
36823.............. Insertion of cannula(s)... .................. C................. ........... ........... ........... ........... ...........
36825.............. Artery-vein autograft..... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
36830.............. Artery-vein nonautograft.. .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
36831.............. Open thrombect av fistula. .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
36832.............. Av fistula revision, open. .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
36833.............. Av fistula revision....... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
36834.............. Repair A-V aneurysm....... .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
36835.............. Artery to vein shunt...... .................. T................. 0115 29.6965 $1,891.49 ........... $378.30
36838.............. Dist revas ligation, hemo. .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
36860.............. External cannula .................. T................. 0676 2.4824 $158.11 ........... $31.62
declotting.
36861.............. Cannula declotting........ .................. T................. 0115 29.6965 $1,891.49 ........... $378.30
36870.............. Percut thrombect av .................. T................. 0653 40.4667 $2,577.49 ........... $515.50
fistula.
37140.............. Revision of circulation... .................. C................. ........... ........... ........... ........... ...........
37145.............. Revision of circulation... .................. C................. ........... ........... ........... ........... ...........
37160.............. Revision of circulation... .................. C................. ........... ........... ........... ........... ...........
37180.............. Revision of circulation... .................. C................. ........... ........... ........... ........... ...........
37181.............. Splice spleen/kidney veins .................. C................. ........... ........... ........... ........... ...........
37182.............. Insert hepatic shunt .................. C................. ........... ........... ........... ........... ...........
(tips).
37183.............. Remove hepatic shunt .................. T................. 0229 88.5367 $5,639.26 ........... $1,127.85
(tips).
37184.............. Prim art mech thrombectomy .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
37185.............. Prim art m-thrombect add- .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
on.
37186.............. Sec art m-thrombect add-on .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
37187.............. Venous mech thrombectomy.. .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
37188.............. Venous m-thrombectomy add- .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
on.
37195.............. Thrombolytic therapy, .................. T................. 0676 2.4824 $158.11 ........... $31.62
stroke.
37200.............. Transcatheter biopsy...... CH................ T................. 0623 28.8743 $1,839.12 ........... $367.82
37201.............. Transcatheter therapy CH................ T................. 0103 14.6576 $933.60 ........... $186.72
infuse.
37202.............. Transcatheter therapy CH................ T................. 0103 14.6576 $933.60 ........... $186.72
infuse.
37203.............. Transcatheter retrieval... CH................ T................. 0623 28.8743 $1,839.12 ........... $367.82
37204.............. Transcatheter occlusion... CH................ T................. 0082 87.5137 $5,574.10 ........... $1,114.82
37205.............. Transcath iv stent, percut .................. T................. 0229 88.5367 $5,639.26 ........... $1,127.85
37206.............. Transcath iv stent/perc .................. T................. 0229 88.5367 $5,639.26 ........... $1,127.85
addl.
37207.............. Transcath iv stent, open.. .................. T................. 0229 88.5367 $5,639.26 ........... $1,127.85
37208.............. Transcath iv stent/open .................. T................. 0229 88.5367 $5,639.26 ........... $1,127.85
addl.
37209.............. Change iv cath at thromb CH................ T................. 0623 28.8743 $1,839.12 ........... $367.82
tx.
37210.............. Embolization uterine CH................ T................. 0229 88.5367 $5,639.26 ........... $1,127.85
fibroid.
37215.............. Transcath stent, cca w/eps .................. C................. ........... ........... ........... ........... ...........
37216.............. Transcath stent, cca w/o .................. E................. ........... ........... ........... ........... ...........
eps.
37250.............. Iv us first vessel add-on. CH................ N................. ........... ........... ........... ........... ...........
37251.............. Iv us each add vessel add- CH................ N................. ........... ........... ........... ........... ...........
on.
37500.............. Endoscopy ligate perf .................. T................. 0091 42.6114 $2,714.09 ........... $542.82
veins.
37501.............. Vascular endoscopy .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
procedure.
37565.............. Ligation of neck vein..... .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
37600.............. Ligation of neck artery... .................. T................. 0093 30.1294 $1,919.06 ........... $383.81
37605.............. Ligation of neck artery... .................. T................. 0091 42.6114 $2,714.09 ........... $542.82
37606.............. Ligation of neck artery... .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
37607.............. Ligation of a-v fistula... .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
37609.............. Temporal artery procedure. .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
37615.............. Ligation of neck artery... .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
37616.............. Ligation of chest artery.. .................. C................. ........... ........... ........... ........... ...........
37617.............. Ligation of abdomen artery .................. C................. ........... ........... ........... ........... ...........
37618.............. Ligation of extremity .................. C................. ........... ........... ........... ........... ...........
artery.
37620.............. Revision of major vein.... .................. T................. 0091 42.6114 $2,714.09 ........... $542.82
37650.............. Revision of major vein.... .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
37660.............. Revision of major vein.... .................. C................. ........... ........... ........... ........... ...........
37700.............. Revise leg vein........... CH................ T................. 0092 25.8410 $1,645.92 ........... $329.18
37718.............. Ligate/strip short leg CH................ T................. 0092 25.8410 $1,645.92 ........... $329.18
vein.
37722.............. Ligate/strip long leg vein .................. T................. 0091 42.6114 $2,714.09 ........... $542.82
37735.............. Removal of leg veins/ .................. T................. 0091 42.6114 $2,714.09 ........... $542.82
lesion.
37760.............. Ligation, leg veins, open. .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
37765.............. Phleb veins extrem 10-20.. .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
37766.............. Phleb veins extrem 20+.... .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
37780.............. Revision of leg vein...... .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
[[Page 67037]]
37785.............. Ligate/divide/excise vein. .................. T................. 0092 25.8410 $1,645.92 ........... $329.18
37788.............. Revascularization, penis.. .................. C................. ........... ........... ........... ........... ...........
37790.............. Penile venous occlusion... .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
37799.............. Vascular surgery procedure .................. T................. 0103 14.6576 $933.60 ........... $186.72
38100.............. Removal of spleen, total.. .................. C................. ........... ........... ........... ........... ...........
38101.............. Removal of spleen, partial .................. C................. ........... ........... ........... ........... ...........
38102.............. Removal of spleen, total.. .................. C................. ........... ........... ........... ........... ...........
38115.............. Repair of ruptured spleen. .................. C................. ........... ........... ........... ........... ...........
38120.............. Laparoscopy, splenectomy.. .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
38129.............. Laparoscope proc, spleen.. .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
38200.............. Injection for spleen x-ray .................. N................. ........... ........... ........... ........... ...........
38204.............. Bl donor search management .................. N................. ........... ........... ........... ........... ...........
38205.............. Harvest allogenic stem .................. S................. 0111 11.5058 $732.85 $198.40 $146.57
cells.
38206.............. Harvest auto stem cells... .................. S................. 0111 11.5058 $732.85 $198.40 $146.57
38207.............. Cryopreserve stem cells... CH................ S................. 0110 3.3967 $216.35 ........... $43.27
38208.............. Thaw preserved stem cells. CH................ S................. 0110 3.3967 $216.35 ........... $43.27
38209.............. Wash harvest stem cells... CH................ S................. 0110 3.3967 $216.35 ........... $43.27
38210.............. T-cell depletion of CH................ S................. 0393 5.6921 $362.55 $82.04 $72.51
harvest.
38211.............. Tumor cell deplete of CH................ S................. 0393 5.6921 $362.55 $82.04 $72.51
harvest.
38212.............. Rbc depletion of harvest.. CH................ S................. 0393 5.6921 $362.55 $82.04 $72.51
38213.............. Platelet deplete of CH................ S................. 0393 5.6921 $362.55 $82.04 $72.51
harvest.
38214.............. Volume deplete of harvest. CH................ S................. 0393 5.6921 $362.55 $82.04 $72.51
38215.............. Harvest stem cell CH................ S................. 0393 5.6921 $362.55 $82.04 $72.51
concentrate.
38220.............. Bone marrow aspiration.... .................. T................. 0003 3.1008 $197.50 ........... $39.50
38221.............. Bone marrow biopsy........ .................. T................. 0003 3.1008 $197.50 ........... $39.50
38230.............. Bone marrow collection.... CH................ S................. 0112 30.6035 $1,949.26 $433.29 $389.85
38240.............. Bone marrow/stem CH................ S................. 0112 30.6035 $1,949.26 $433.29 $389.85
transplant.
38241.............. Bone marrow/stem CH................ S................. 0112 30.6035 $1,949.26 $433.29 $389.85
transplant.
38242.............. Lymphocyte infuse .................. S................. 0111 11.5058 $732.85 $198.40 $146.57
transplant.
38300.............. Drainage, lymph node .................. T................. 0007 11.5594 $736.26 ........... $147.25
lesion.
38305.............. Drainage, lymph node .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
lesion.
38308.............. Incision of lymph channels .................. T................. 0113 22.9584 $1,462.31 ........... $292.46
38380.............. Thoracic duct procedure... .................. C................. ........... ........... ........... ........... ...........
38381.............. Thoracic duct procedure... .................. C................. ........... ........... ........... ........... ...........
38382.............. Thoracic duct procedure... .................. C................. ........... ........... ........... ........... ...........
38500.............. Biopsy/removal, lymph .................. T................. 0113 22.9584 $1,462.31 ........... $292.46
nodes.
38505.............. Needle biopsy, lymph nodes .................. T................. 0005 7.1147 $453.16 ........... $90.63
38510.............. Biopsy/removal, lymph .................. T................. 0113 22.9584 $1,462.31 ........... $292.46
nodes.
38520.............. Biopsy/removal, lymph .................. T................. 0113 22.9584 $1,462.31 ........... $292.46
nodes.
38525.............. Biopsy/removal, lymph .................. T................. 0113 22.9584 $1,462.31 ........... $292.46
nodes.
38530.............. Biopsy/removal, lymph .................. T................. 0113 22.9584 $1,462.31 ........... $292.46
nodes.
38542.............. Explore deep node(s), neck .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
38550.............. Removal, neck/armpit .................. T................. 0113 22.9584 $1,462.31 ........... $292.46
lesion.
38555.............. Removal, neck/armpit .................. T................. 0113 22.9584 $1,462.31 ........... $292.46
lesion.
38562.............. Removal, pelvic lymph .................. C................. ........... ........... ........... ........... ...........
nodes.
38564.............. Removal, abdomen lymph .................. C................. ........... ........... ........... ........... ...........
nodes.
38570.............. Laparoscopy, lymph node .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
biop.
38571.............. Laparoscopy, .................. T................. 0132 69.6652 $4,437.26 $1,239.22 $887.45
lymphadenectomy.
38572.............. Laparoscopy, .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
lymphadenectomy.
38589.............. Laparoscope proc, .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
lymphatic.
38700.............. Removal of lymph nodes, .................. T................. 0113 22.9584 $1,462.31 ........... $292.46
neck.
38720.............. Removal of lymph nodes, .................. T................. 0113 22.9584 $1,462.31 ........... $292.46
neck.
38724.............. Removal of lymph nodes, .................. C................. ........... ........... ........... ........... ...........
neck.
38740.............. Remove armpit lymph nodes. .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
38745.............. Remove armpit lymph nodes. .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
38746.............. Remove thoracic lymph .................. C................. ........... ........... ........... ........... ...........
nodes.
38747.............. Remove abdominal lymph .................. C................. ........... ........... ........... ........... ...........
nodes.
38760.............. Remove groin lymph nodes.. .................. T................. 0113 22.9584 $1,462.31 ........... $292.46
38765.............. Remove groin lymph nodes.. .................. C................. ........... ........... ........... ........... ...........
38770.............. Remove pelvis lymph nodes. .................. C................. ........... ........... ........... ........... ...........
38780.............. Remove abdomen lymph nodes .................. C................. ........... ........... ........... ........... ...........
38790.............. Inject for lymphatic x-ray .................. N................. ........... ........... ........... ........... ...........
38792.............. Identify sentinel node.... CH................ Q................. 0392 2.9022 $184.85 $49.31 $36.97
38794.............. Access thoracic lymph duct .................. N................. ........... ........... ........... ........... ...........
38999.............. Blood/lymph system .................. S................. 0110 3.3967 $216.35 ........... $43.27
procedure.
39000.............. Exploration of chest...... .................. C................. ........... ........... ........... ........... ...........
39010.............. Exploration of chest...... .................. C................. ........... ........... ........... ........... ...........
39200.............. Removal chest lesion...... .................. C................. ........... ........... ........... ........... ...........
39220.............. Removal chest lesion...... .................. C................. ........... ........... ........... ........... ...........
39400.............. Visualization of chest.... .................. T................. 0069 32.5666 $2,074.30 $591.64 $414.86
39499.............. Chest procedure........... .................. C................. ........... ........... ........... ........... ...........
39501.............. Repair diaphragm .................. C................. ........... ........... ........... ........... ...........
laceration.
39502.............. Repair paraesophageal .................. C................. ........... ........... ........... ........... ...........
hernia.
39503.............. Repair of diaphragm hernia .................. C................. ........... ........... ........... ........... ...........
39520.............. Repair of diaphragm hernia .................. C................. ........... ........... ........... ........... ...........
39530.............. Repair of diaphragm hernia .................. C................. ........... ........... ........... ........... ...........
39531.............. Repair of diaphragm hernia .................. C................. ........... ........... ........... ........... ...........
39540.............. Repair of diaphragm hernia .................. C................. ........... ........... ........... ........... ...........
39541.............. Repair of diaphragm hernia .................. C................. ........... ........... ........... ........... ...........
39545.............. Revision of diaphragm..... .................. C................. ........... ........... ........... ........... ...........
[[Page 67038]]
39560.............. Resect diaphragm, simple.. .................. C................. ........... ........... ........... ........... ...........
39561.............. Resect diaphragm, complex. .................. C................. ........... ........... ........... ........... ...........
39599.............. Diaphragm surgery .................. C................. ........... ........... ........... ........... ...........
procedure.
4000F.............. Tobacco use txmnt .................. M................. ........... ........... ........... ........... ...........
counseling.
4001F.............. Tobacco use txmnt, .................. M................. ........... ........... ........... ........... ...........
pharmacol.
4002F.............. Statin therapy, rx........ .................. M................. ........... ........... ........... ........... ...........
4003F.............. Pt ed write/oral, pts w/ .................. M................. ........... ........... ........... ........... ...........
hf.
4005F.............. Pharm thx for op rx'd..... .................. M................. ........... ........... ........... ........... ...........
4006F.............. Beta-blocker therapy rx... .................. M................. ........... ........... ........... ........... ...........
4007F.............. Areds/anitox vit/min rx'd. CH................ D................. ........... ........... ........... ........... ...........
4009F.............. Ace/arb inhibitor therapy .................. M................. ........... ........... ........... ........... ...........
rx.
4011F.............. Oral antiplatelet therapy .................. M................. ........... ........... ........... ........... ...........
rx.
4012F.............. Warfarin therapy rx....... .................. M................. ........... ........... ........... ........... ...........
4014F.............. Written discharge instr .................. M................. ........... ........... ........... ........... ...........
prvd.
4015F.............. Persist asthma medicine .................. M................. ........... ........... ........... ........... ...........
ctrl.
4016F.............. Anti-inflm/anlgsc agent rx .................. M................. ........... ........... ........... ........... ...........
4017F.............. Gi prophylaxis for nsaid .................. M................. ........... ........... ........... ........... ...........
rx.
4018F.............. Therapy exercise joint rx. .................. M................. ........... ........... ........... ........... ...........
4019F.............. Doc recpt counsl vit d/ .................. M................. ........... ........... ........... ........... ...........
calc+.
4025F.............. Inhaled bronchodilator rx. .................. M................. ........... ........... ........... ........... ...........
4030F.............. Oxygen therapy rx......... .................. M................. ........... ........... ........... ........... ...........
4033F.............. Pulmonary rehab rec....... .................. M................. ........... ........... ........... ........... ...........
4035F.............. Influenza imm rec......... .................. M................. ........... ........... ........... ........... ...........
4037F.............. Influenza imm order/admin. .................. M................. ........... ........... ........... ........... ...........
4040F.............. Pneumoc imm order/admin... .................. M................. ........... ........... ........... ........... ...........
4041F.............. Doc order cefazolin/ .................. M................. ........... ........... ........... ........... ...........
cefurox.
4042F.............. Doc antibio not given..... .................. M................. ........... ........... ........... ........... ...........
4043F.............. Doc order given stop .................. M................. ........... ........... ........... ........... ...........
antibio.
4044F.............. Doc order given vte .................. M................. ........... ........... ........... ........... ...........
prophylx.
4045F.............. Empiric antibiotic rx..... .................. M................. ........... ........... ........... ........... ...........
4046F.............. Doc antibio given b/4 surg .................. M................. ........... ........... ........... ........... ...........
4047F.............. Doc antibio given b/4 surg .................. M................. ........... ........... ........... ........... ...........
4048F.............. Doc antibio given b/4 surg .................. M................. ........... ........... ........... ........... ...........
40490.............. Biopsy of lip............. .................. T................. 0251 2.5002 $159.25 ........... $31.85
4049F.............. Doc order given stop .................. M................. ........... ........... ........... ........... ...........
antibio.
40500.............. Partial excision of lip... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
4050F.............. Ht care plan doc.......... .................. M................. ........... ........... ........... ........... ...........
40510.............. Partial excision of lip... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
4051F.............. Referred for an AV fistula .................. M................. ........... ........... ........... ........... ...........
40520.............. Partial excision of lip... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
40525.............. Reconstruct lip with flap. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
40527.............. Reconstruct lip with flap. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
4052F.............. Hemodialysis via AV .................. M................. ........... ........... ........... ........... ...........
fistula.
40530.............. Partial removal of lip.... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
4053F.............. Hemodialysis via AV graft. .................. M................. ........... ........... ........... ........... ...........
4054F.............. Hemodialysis via catheter. .................. M................. ........... ........... ........... ........... ...........
4055F.............. Pt rcvng periton dialysis. .................. M................. ........... ........... ........... ........... ...........
4056F.............. Approp oral rehyd recomm'd .................. M................. ........... ........... ........... ........... ...........
4058F.............. Ped gastro ed given, .................. M................. ........... ........... ........... ........... ...........
caregvr.
4060F.............. Psych svcs provided....... .................. M................. ........... ........... ........... ........... ...........
4062F.............. Pt referral psych doc'd... .................. M................. ........... ........... ........... ........... ...........
4064F.............. Antidepressant rx......... .................. M................. ........... ........... ........... ........... ...........
40650.............. Repair lip................ .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
40652.............. Repair lip................ .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
40654.............. Repair lip................ .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
4065F.............. Antipsychotic rx.......... .................. M................. ........... ........... ........... ........... ...........
4066F.............. ECT provided.............. .................. M................. ........... ........... ........... ........... ...........
4067F.............. Pt referral for ECT doc'd. .................. M................. ........... ........... ........... ........... ...........
40700.............. Repair cleft lip/nasal.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
40701.............. Repair cleft lip/nasal.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
40702.............. Repair cleft lip/nasal.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
4070F.............. Dvt prophylx recv'd day 2. .................. M................. ........... ........... ........... ........... ...........
40720.............. Repair cleft lip/nasal.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
4073F.............. Oral antiplat thx rx .................. M................. ........... ........... ........... ........... ...........
dischrg.
4075F.............. Anticoag thx rx at dischrg .................. M................. ........... ........... ........... ........... ...........
40761.............. Repair cleft lip/nasal.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
4077F.............. Doc t-pa admin considered. .................. M................. ........... ........... ........... ........... ...........
40799.............. Lip surgery procedure..... .................. T................. 0251 2.5002 $159.25 ........... $31.85
4079F.............. Doc rehab svcs considered. .................. M................. ........... ........... ........... ........... ...........
40800.............. Drainage of mouth lesion.. .................. T................. 0006 1.4066 $89.59 ........... $17.92
40801.............. Drainage of mouth lesion.. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
40804.............. Removal, foreign body, .................. X................. 0340 0.6310 $40.19 ........... $8.04
mouth.
40805.............. Removal, foreign body, .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
mouth.
40806.............. Incision of lip fold...... .................. T................. 0251 2.5002 $159.25 ........... $31.85
40808.............. Biopsy of mouth lesion.... .................. T................. 0251 2.5002 $159.25 ........... $31.85
40810.............. Excision of mouth lesion.. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
40812.............. Excise/repair mouth lesion .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
40814.............. Excise/repair mouth lesion .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
40816.............. Excision of mouth lesion.. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
40818.............. Excise oral mucosa for .................. T................. 0251 2.5002 $159.25 ........... $31.85
graft.
[[Page 67039]]
40819.............. Excise lip or cheek fold.. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
40820.............. Treatment of mouth lesion. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
40830.............. Repair mouth laceration... .................. T................. 0251 2.5002 $159.25 ........... $31.85
40831.............. Repair mouth laceration... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
40840.............. Reconstruction of mouth... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
40842.............. Reconstruction of mouth... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
40843.............. Reconstruction of mouth... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
40844.............. Reconstruction of mouth... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
40845.............. Reconstruction of mouth... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
4084F.............. Aspirin recv'd w/in 24 hrs .................. M................. ........... ........... ........... ........... ...........
40899.............. Mouth surgery procedure... .................. T................. 0251 2.5002 $159.25 ........... $31.85
4090F.............. Pt rcvng epo thxpy........ .................. M................. ........... ........... ........... ........... ...........
4095F.............. Pt not rcvng epo thxpy.... .................. M................. ........... ........... ........... ........... ...........
41000.............. Drainage of mouth lesion.. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41005.............. Drainage of mouth lesion.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
41006.............. Drainage of mouth lesion.. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
41007.............. Drainage of mouth lesion.. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41008.............. Drainage of mouth lesion.. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41009.............. Drainage of mouth lesion.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
4100F.............. Biphos thxpy vein ord/ .................. M................. ........... ........... ........... ........... ...........
rec'vd.
41010.............. Incision of tongue fold... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
41015.............. Drainage of mouth lesion.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
41016.............. Drainage of mouth lesion.. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
41017.............. Drainage of mouth lesion.. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
41018.............. Drainage of mouth lesion.. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
41019.............. Place needles h&n for rt.. NI................ T................. 0254 23.9765 $1,527.16 $321.35 $305.43
41100.............. Biopsy of tongue.......... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
41105.............. Biopsy of tongue.......... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41108.............. Biopsy of floor of mouth.. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
4110F.............. Int mam art used for cabg. .................. M................. ........... ........... ........... ........... ...........
41110.............. Excision of tongue lesion. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41112.............. Excision of tongue lesion. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41113.............. Excision of tongue lesion. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41114.............. Excision of tongue lesion. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
41115.............. Excision of tongue fold... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
41116.............. Excision of mouth lesion.. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41120.............. Partial removal of tongue. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
41130.............. Partial removal of tongue. .................. C................. ........... ........... ........... ........... ...........
41135.............. Tongue and neck surgery... .................. C................. ........... ........... ........... ........... ...........
41140.............. Removal of tongue......... .................. C................. ........... ........... ........... ........... ...........
41145.............. Tongue removal, neck .................. C................. ........... ........... ........... ........... ...........
surgery.
41150.............. Tongue, mouth, jaw surgery .................. C................. ........... ........... ........... ........... ...........
41153.............. Tongue, mouth, neck .................. C................. ........... ........... ........... ........... ...........
surgery.
41155.............. Tongue, jaw, & neck .................. C................. ........... ........... ........... ........... ...........
surgery.
4115F.............. Beta blckr admin w/in 24 .................. M................. ........... ........... ........... ........... ...........
hrs.
4120F.............. Antibiot rx'd/given....... .................. M................. ........... ........... ........... ........... ...........
4124F.............. Antibiot not rx'd/given... .................. M................. ........... ........... ........... ........... ...........
41250.............. Repair tongue laceration.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
41251.............. Repair tongue laceration.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
41252.............. Repair tongue laceration.. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
4130F.............. Topical prep rx, AOE...... .................. M................. ........... ........... ........... ........... ...........
4131F.............. Syst antimicrobial thx rx. .................. M................. ........... ........... ........... ........... ...........
4132F.............. No syst antimicrobial thx .................. M................. ........... ........... ........... ........... ...........
rx.
4133F.............. Antihist/decong rx/recom.. .................. M................. ........... ........... ........... ........... ...........
4134F.............. No antihist/decong rx/ .................. M................. ........... ........... ........... ........... ...........
recom.
4135F.............. Systemic corticosteroids .................. M................. ........... ........... ........... ........... ...........
rx.
4136F.............. Syst corticosteroids not .................. M................. ........... ........... ........... ........... ...........
rx.
41500.............. Fixation of tongue........ .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
4150F.............. Pt recvng antivir txmnt .................. M................. ........... ........... ........... ........... ...........
hepc.
41510.............. Tongue to lip surgery..... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
4151F.............. Pt not recvng antiv hep c. .................. M................. ........... ........... ........... ........... ...........
41520.............. Reconstruction, tongue .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
fold.
4152F.............. Doc'd pegintf/rib thxy .................. M................. ........... ........... ........... ........... ...........
consd.
4153F.............. Combo pegintf/rib rx...... .................. M................. ........... ........... ........... ........... ...........
4154F.............. Hep A vac series .................. M................. ........... ........... ........... ........... ...........
recommended.
4155F.............. Hep A vac series prev .................. M................. ........... ........... ........... ........... ...........
recvd.
4156F.............. Hep B vac series .................. M................. ........... ........... ........... ........... ...........
recommended.
4157F.............. Hep B vac series prev .................. M................. ........... ........... ........... ........... ...........
recvd.
4158F.............. Pt edu re: alcoh drnkng .................. M................. ........... ........... ........... ........... ...........
done.
41599.............. Tongue and mouth surgery.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
4159F.............. Contrcp talk b/4 antiv .................. M................. ........... ........... ........... ........... ...........
txmnt.
4163F.............. Pt couns. 4 txmnt opt, NI................ M................. ........... ........... ........... ........... ...........
prost.
4164F.............. Adjv hrmnl thxpy Rx'd..... NI................ M................. ........... ........... ........... ........... ...........
4165F.............. 3D-CRT/IMRT received...... NI................ M................. ........... ........... ........... ........... ...........
4167F.............. Hd Bed tilted, 1st day NI................ M................. ........... ........... ........... ........... ...........
vent.
4168F.............. Pt care, ICU&vent w/in NI................ M................. ........... ........... ........... ........... ...........
24hrs.
4169F.............. No pt care ICU/vent in NI................ M................. ........... ........... ........... ........... ...........
24hrs.
4171F.............. Pt. rcvng ESA thxpy....... NI................ M................. ........... ........... ........... ........... ...........
4172F.............. Pt. not rcvng ESA thxpy... NI................ M................. ........... ........... ........... ........... ...........
4174F.............. Couns., potent. Glauc NI................ M................. ........... ........... ........... ........... ...........
impct.
[[Page 67040]]
4175F.............. Vis of >=20/40 w/in 90 NI................ M................. ........... ........... ........... ........... ...........
days.
4176F.............. Talk re UV light, pt/crgvr NI................ M................. ........... ........... ........... ........... ...........
4177F.............. Talk pt/crgvr re: NI................ M................. ........... ........... ........... ........... ...........
AREDS,prev.
4178F.............. AntiD glbln rcv'd w/in NI................ M................. ........... ........... ........... ........... ...........
26wks.
4179F.............. Tamoxifen/AI prescribed... NI................ M................. ........... ........... ........... ........... ...........
41800.............. Drainage of gum lesion.... .................. T................. 0006 1.4066 $89.59 ........... $17.92
41805.............. Removal foreign body, gum. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
41806.............. Removal foreign body, .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
jawbone.
4180F.............. Adjv thxpyRx'd/rcv'd Stg3A- NI................ M................. ........... ........... ........... ........... ...........
C.
4181F.............. Conformal rad'n thxpy NI................ M................. ........... ........... ........... ........... ...........
rcv'd.
41820.............. Excision, gum, each .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
quadrant.
41821.............. Excision of gum flap...... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
41822.............. Excision of gum lesion.... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41823.............. Excision of gum lesion.... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
41825.............. Excision of gum lesion.... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41826.............. Excision of gum lesion.... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41827.............. Excision of gum lesion.... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
41828.............. Excision of gum lesion.... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
4182F.............. No conformal rad'n thxpy.. NI................ M................. ........... ........... ........... ........... ...........
41830.............. Removal of gum tissue..... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41850.............. Treatment of gum lesion... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
4185F.............. Continuous PPI or H2RA NI................ M................. ........... ........... ........... ........... ...........
rcv'd.
4186F.............. No Cont. PPI or H2RA rcv'd NI................ M................. ........... ........... ........... ........... ...........
41870.............. Gum graft................. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
41872.............. Repair gum................ .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
41874.............. Repair tooth socket....... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
4187F.............. Anti rheum DrugthxpyRx'd/ NI................ M................. ........... ........... ........... ........... ...........
gvn.
4188F.............. Approp ACE/ARB tstng done. NI................ M................. ........... ........... ........... ........... ...........
41899.............. Dental surgery procedure.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
4189F.............. Approp dogoxin tstng done. NI................ M................. ........... ........... ........... ........... ...........
4190F.............. Approp diuretic tstng done NI................ M................. ........... ........... ........... ........... ...........
4191F.............. Approp anticonvuls tstng.. NI................ M................. ........... ........... ........... ........... ...........
42000.............. Drainage mouth roof lesion .................. T................. 0251 2.5002 $159.25 ........... $31.85
4200F.............. External beam to prost NI................ M................. ........... ........... ........... ........... ...........
only.
4201F.............. Extrnl beam other than NI................ M................. ........... ........... ........... ........... ...........
prost.
42100.............. Biopsy roof of mouth...... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
42104.............. Excision lesion, mouth .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
roof.
42106.............. Excision lesion, mouth .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
roof.
42107.............. Excision lesion, mouth .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
roof.
4210F.............. ACE/ARB thxpy for >= 6 NI................ M................. ........... ........... ........... ........... ...........
mons.
42120.............. Remove palate/lesion...... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42140.............. Excision of uvula......... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
42145.............. Repair palate, pharynx/ .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
uvula.
42160.............. Treatment mouth roof .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
lesion.
42180.............. Repair palate............. .................. T................. 0251 2.5002 $159.25 ........... $31.85
42182.............. Repair palate............. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42200.............. Reconstruct cleft palate.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42205.............. Reconstruct cleft palate.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
4220F.............. Digoxin thxpy for >= 6 NI................ M................. ........... ........... ........... ........... ...........
mons.
42210.............. Reconstruct cleft palate.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42215.............. Reconstruct cleft palate.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
4221F.............. Diuretic thxpy for >= 6 NI................ M................. ........... ........... ........... ........... ...........
mons.
42220.............. Reconstruct cleft palate.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42225.............. Reconstruct cleft palate.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42226.............. Lengthening of palate..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42227.............. Lengthening of palate..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42235.............. Repair palate............. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
42260.............. Repair nose to lip fistula .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
42280.............. Preparation, palate mold.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
42281.............. Insertion, palate .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
prosthesis.
42299.............. Palate/uvula surgery...... .................. T................. 0251 2.5002 $159.25 ........... $31.85
42300.............. Drainage of salivary gland .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
42305.............. Drainage of salivary gland .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
4230F.............. Anticonv thxpy for >= 6 NI................ M................. ........... ........... ........... ........... ...........
mons.
42310.............. Drainage of salivary gland .................. T................. 0251 2.5002 $159.25 ........... $31.85
42320.............. Drainage of salivary gland .................. T................. 0251 2.5002 $159.25 ........... $31.85
42330.............. Removal of salivary stone. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
42335.............. Removal of salivary stone. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
42340.............. Removal of salivary stone. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
42400.............. Biopsy of salivary gland.. .................. T................. 0005 7.1147 $453.16 ........... $90.63
42405.............. Biopsy of salivary gland.. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
42408.............. Excision of salivary cyst. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
42409.............. Drainage of salivary cyst. .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
42410.............. Excise parotid gland/ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
lesion.
42415.............. Excise parotid gland/ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
lesion.
42420.............. Excise parotid gland/ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
lesion.
42425.............. Excise parotid gland/ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
lesion.
42426.............. Excise parotid gland/ .................. C................. ........... ........... ........... ........... ...........
lesion.
42440.............. Excise submaxillary gland. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42450.............. Excise sublingual gland... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
[[Page 67041]]
42500.............. Repair salivary duct...... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
42505.............. Repair salivary duct...... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42507.............. Parotid duct diversion.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42508.............. Parotid duct diversion.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42509.............. Parotid duct diversion.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42510.............. Parotid duct diversion.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42550.............. Injection for salivary x- .................. N................. ........... ........... ........... ........... ...........
ray.
42600.............. Closure of salivary .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
fistula.
42650.............. Dilation of salivary duct. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
42660.............. Dilation of salivary duct. .................. T................. 0251 2.5002 $159.25 ........... $31.85
42665.............. Ligation of salivary duct. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
42699.............. Salivary surgery procedure .................. T................. 0251 2.5002 $159.25 ........... $31.85
42700.............. Drainage of tonsil abscess .................. T................. 0251 2.5002 $159.25 ........... $31.85
42720.............. Drainage of throat abscess .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
42725.............. Drainage of throat abscess .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42800.............. Biopsy of throat.......... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
42802.............. Biopsy of throat.......... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
42804.............. Biopsy of upper nose/ .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
throat.
42806.............. Biopsy of upper nose/ .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
throat.
42808.............. Excise pharynx lesion..... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
42809.............. Remove pharynx foreign .................. X................. 0340 0.6310 $40.19 ........... $8.04
body.
42810.............. Excision of neck cyst..... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
42815.............. Excision of neck cyst..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42820.............. Remove tonsils and .................. T................. 0258 22.2557 $1,417.55 $437.25 $283.51
adenoids.
42821.............. Remove tonsils and .................. T................. 0258 22.2557 $1,417.55 $437.25 $283.51
adenoids.
42825.............. Removal of tonsils........ .................. T................. 0258 22.2557 $1,417.55 $437.25 $283.51
42826.............. Removal of tonsils........ .................. T................. 0258 22.2557 $1,417.55 $437.25 $283.51
42830.............. Removal of adenoids....... .................. T................. 0258 22.2557 $1,417.55 $437.25 $283.51
42831.............. Removal of adenoids....... .................. T................. 0258 22.2557 $1,417.55 $437.25 $283.51
42835.............. Removal of adenoids....... .................. T................. 0258 22.2557 $1,417.55 $437.25 $283.51
42836.............. Removal of adenoids....... .................. T................. 0258 22.2557 $1,417.55 $437.25 $283.51
42842.............. Extensive surgery of .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
throat.
42844.............. Extensive surgery of .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
throat.
42845.............. Extensive surgery of .................. C................. ........... ........... ........... ........... ...........
throat.
42860.............. Excision of tonsil tags... .................. T................. 0258 22.2557 $1,417.55 $437.25 $283.51
42870.............. Excision of lingual tonsil .................. T................. 0258 22.2557 $1,417.55 $437.25 $283.51
42890.............. Partial removal of pharynx .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42892.............. Revision of pharyngeal .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
walls.
42894.............. Revision of pharyngeal .................. C................. ........... ........... ........... ........... ...........
walls.
42900.............. Repair throat wound....... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
42950.............. Reconstruction of throat.. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
42953.............. Repair throat, esophagus.. .................. C................. ........... ........... ........... ........... ...........
42955.............. Surgical opening of throat .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
42960.............. Control throat bleeding... .................. T................. 0250 1.1251 $71.66 $25.10 $14.33
42961.............. Control throat bleeding... .................. C................. ........... ........... ........... ........... ...........
42962.............. Control throat bleeding... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
42970.............. Control nose/throat .................. T................. 0250 1.1251 $71.66 $25.10 $14.33
bleeding.
42971.............. Control nose/throat .................. C................. ........... ........... ........... ........... ...........
bleeding.
42972.............. Control nose/throat .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
bleeding.
42999.............. Throat surgery procedure.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
43020.............. Incision of esophagus..... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
43030.............. Throat muscle surgery..... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
43045.............. Incision of esophagus..... .................. C................. ........... ........... ........... ........... ...........
43100.............. Excision of esophagus .................. C................. ........... ........... ........... ........... ...........
lesion.
43101.............. Excision of esophagus .................. C................. ........... ........... ........... ........... ...........
lesion.
43107.............. Removal of esophagus...... .................. C................. ........... ........... ........... ........... ...........
43108.............. Removal of esophagus...... .................. C................. ........... ........... ........... ........... ...........
43112.............. Removal of esophagus...... .................. C................. ........... ........... ........... ........... ...........
43113.............. Removal of esophagus...... .................. C................. ........... ........... ........... ........... ...........
43116.............. Partial removal of .................. C................. ........... ........... ........... ........... ...........
esophagus.
43117.............. Partial removal of .................. C................. ........... ........... ........... ........... ...........
esophagus.
43118.............. Partial removal of .................. C................. ........... ........... ........... ........... ...........
esophagus.
43121.............. Partial removal of .................. C................. ........... ........... ........... ........... ...........
esophagus.
43122.............. Partial removal of .................. C................. ........... ........... ........... ........... ...........
esophagus.
43123.............. Partial removal of .................. C................. ........... ........... ........... ........... ...........
esophagus.
43124.............. Removal of esophagus...... .................. C................. ........... ........... ........... ........... ...........
43130.............. Removal of esophagus pouch .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
43135.............. Removal of esophagus pouch .................. C................. ........... ........... ........... ........... ...........
43200.............. Esophagus endoscopy....... .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43201.............. Esoph scope w/submucous .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
inj.
43202.............. Esophagus endoscopy, .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
biopsy.
43204.............. Esoph scope w/sclerosis .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
inj.
43205.............. Esophagus endoscopy/ .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
ligation.
43215.............. Esophagus endoscopy....... .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43216.............. Esophagus endoscopy/lesion .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43217.............. Esophagus endoscopy....... .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43219.............. Esophagus endoscopy....... .................. T................. 0384 24.9814 $1,591.17 ........... $318.23
43220.............. Esoph endoscopy, dilation. .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43226.............. Esoph endoscopy, dilation. .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43227.............. Esoph endoscopy, repair... .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
[[Page 67042]]
43228.............. Esoph endoscopy, ablation. .................. T................. 0422 25.3233 $1,612.94 $448.81 $322.59
43231.............. Esoph endoscopy w/us exam. .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43232.............. Esoph endoscopy w/us fn bx .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43234.............. Upper GI endoscopy, exam.. .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43235.............. Uppr gi endoscopy, .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
diagnosis.
43236.............. Uppr gi scope w/submuc inj .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43237.............. Endoscopic us exam, esoph. .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43238.............. Uppr gi endoscopy w/us fn .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
bx.
43239.............. Upper GI endoscopy, biopsy .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43240.............. Esoph endoscope w/drain .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
cyst.
43241.............. Upper GI endoscopy with .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
tube.
43242.............. Uppr gi endoscopy w/us fn .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
bx.
43243.............. Upper gi endoscopy & .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
inject.
43244.............. Upper GI endoscopy/ .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
ligation.
43245.............. Uppr gi scope dilate .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
strictr.
43246.............. Place gastrostomy tube.... .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43247.............. Operative upper GI .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
endoscopy.
43248.............. Uppr gi endoscopy/guide .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
wire.
43249.............. Esoph endoscopy, dilation. .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43250.............. Upper GI endoscopy/tumor.. .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43251.............. Operative upper GI .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
endoscopy.
43255.............. Operative upper GI .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
endoscopy.
43256.............. Uppr gi endoscopy w/stent. .................. T................. 0384 24.9814 $1,591.17 ........... $318.23
43257.............. Uppr gi scope w/thrml .................. T................. 0422 25.3233 $1,612.94 $448.81 $322.59
txmnt.
43258.............. Operative upper GI .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
endoscopy.
43259.............. Endoscopic ultrasound exam .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43260.............. Endo .................. T................. 0151 20.9510 $1,334.45 ........... $266.89
cholangiopancreatograph.
43261.............. Endo .................. T................. 0151 20.9510 $1,334.45 ........... $266.89
cholangiopancreatograph.
43262.............. Endo .................. T................. 0151 20.9510 $1,334.45 ........... $266.89
cholangiopancreatograph.
43263.............. Endo .................. T................. 0151 20.9510 $1,334.45 ........... $266.89
cholangiopancreatograph.
43264.............. Endo .................. T................. 0151 20.9510 $1,334.45 ........... $266.89
cholangiopancreatograph.
43265.............. Endo .................. T................. 0151 20.9510 $1,334.45 ........... $266.89
cholangiopancreatograph.
43267.............. Endo .................. T................. 0151 20.9510 $1,334.45 ........... $266.89
cholangiopancreatograph.
43268.............. Endo .................. T................. 0384 24.9814 $1,591.17 ........... $318.23
cholangiopancreatograph.
43269.............. Endo .................. T................. 0384 24.9814 $1,591.17 ........... $318.23
cholangiopancreatograph.
43271.............. Endo .................. T................. 0151 20.9510 $1,334.45 ........... $266.89
cholangiopancreatograph.
43272.............. Endo .................. T................. 0151 20.9510 $1,334.45 ........... $266.89
cholangiopancreatograph.
43280.............. Laparoscopy, fundoplasty.. .................. T................. 0132 69.6652 $4,437.26 $1,239.22 $887.45
43289.............. Laparoscope proc, esoph... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
43300.............. Repair of esophagus....... .................. C................. ........... ........... ........... ........... ...........
43305.............. Repair esophagus and .................. C................. ........... ........... ........... ........... ...........
fistula.
43310.............. Repair of esophagus....... .................. C................. ........... ........... ........... ........... ...........
43312.............. Repair esophagus and .................. C................. ........... ........... ........... ........... ...........
fistula.
43313.............. Esophagoplasty congenital. .................. C................. ........... ........... ........... ........... ...........
43314.............. Tracheo-esophagoplasty .................. C................. ........... ........... ........... ........... ...........
cong.
43320.............. Fuse esophagus & stomach.. .................. C................. ........... ........... ........... ........... ...........
43324.............. Revise esophagus & stomach .................. C................. ........... ........... ........... ........... ...........
43325.............. Revise esophagus & stomach .................. C................. ........... ........... ........... ........... ...........
43326.............. Revise esophagus & stomach .................. C................. ........... ........... ........... ........... ...........
43330.............. Repair of esophagus....... .................. C................. ........... ........... ........... ........... ...........
43331.............. Repair of esophagus....... .................. C................. ........... ........... ........... ........... ...........
43340.............. Fuse esophagus & intestine .................. C................. ........... ........... ........... ........... ...........
43341.............. Fuse esophagus & intestine .................. C................. ........... ........... ........... ........... ...........
43350.............. Surgical opening, .................. C................. ........... ........... ........... ........... ...........
esophagus.
43351.............. Surgical opening, .................. C................. ........... ........... ........... ........... ...........
esophagus.
43352.............. Surgical opening, .................. C................. ........... ........... ........... ........... ...........
esophagus.
43360.............. Gastrointestinal repair... .................. C................. ........... ........... ........... ........... ...........
43361.............. Gastrointestinal repair... .................. C................. ........... ........... ........... ........... ...........
43400.............. Ligate esophagus veins.... .................. C................. ........... ........... ........... ........... ...........
43401.............. Esophagus surgery for .................. C................. ........... ........... ........... ........... ...........
veins.
43405.............. Ligate/staple esophagus... .................. C................. ........... ........... ........... ........... ...........
43410.............. Repair esophagus wound.... .................. C................. ........... ........... ........... ........... ...........
43415.............. Repair esophagus wound.... .................. C................. ........... ........... ........... ........... ...........
43420.............. Repair esophagus opening.. .................. C................. ........... ........... ........... ........... ...........
43425.............. Repair esophagus opening.. .................. C................. ........... ........... ........... ........... ...........
43450.............. Dilate esophagus.......... .................. T................. 0140 5.8431 $372.17 $91.40 $74.43
43453.............. Dilate esophagus.......... .................. T................. 0140 5.8431 $372.17 $91.40 $74.43
43456.............. Dilate esophagus.......... .................. T................. 0140 5.8431 $372.17 $91.40 $74.43
43458.............. Dilate esophagus.......... CH................ T................. 0141 8.5030 $541.59 $143.38 $108.32
43460.............. Pressure treatment .................. C................. ........... ........... ........... ........... ...........
esophagus.
43496.............. Free jejunum flap, .................. C................. ........... ........... ........... ........... ...........
microvasc.
43499.............. Esophagus surgery .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
procedure.
43500.............. Surgical opening of .................. C................. ........... ........... ........... ........... ...........
stomach.
43501.............. Surgical repair of stomach .................. C................. ........... ........... ........... ........... ...........
43502.............. Surgical repair of stomach .................. C................. ........... ........... ........... ........... ...........
43510.............. Surgical opening of .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
stomach.
43520.............. Incision of pyloric muscle .................. C................. ........... ........... ........... ........... ...........
43600.............. Biopsy of stomach......... .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43605.............. Biopsy of stomach......... .................. C................. ........... ........... ........... ........... ...........
43610.............. Excision of stomach lesion .................. C................. ........... ........... ........... ........... ...........
[[Page 67043]]
43611.............. Excision of stomach lesion .................. C................. ........... ........... ........... ........... ...........
43620.............. Removal of stomach........ .................. C................. ........... ........... ........... ........... ...........
43621.............. Removal of stomach........ .................. C................. ........... ........... ........... ........... ...........
43622.............. Removal of stomach........ .................. C................. ........... ........... ........... ........... ...........
43631.............. Removal of stomach, .................. C................. ........... ........... ........... ........... ...........
partial.
43632.............. Removal of stomach, .................. C................. ........... ........... ........... ........... ...........
partial.
43633.............. Removal of stomach, .................. C................. ........... ........... ........... ........... ...........
partial.
43634.............. Removal of stomach, .................. C................. ........... ........... ........... ........... ...........
partial.
43635.............. Removal of stomach, .................. C................. ........... ........... ........... ........... ...........
partial.
43640.............. Vagotomy & pylorus repair. .................. C................. ........... ........... ........... ........... ...........
43641.............. Vagotomy & pylorus repair. .................. C................. ........... ........... ........... ........... ...........
43644.............. Lap gastric bypass/roux-en- .................. C................. ........... ........... ........... ........... ...........
y.
43645.............. Lap gastr bypass incl smll .................. C................. ........... ........... ........... ........... ...........
i.
43647.............. Lap impl electrode, antrum CH................ S................. 0061 82.8597 $5,277.67 ........... $1,055.53
43648.............. Lap revise/remv eltrd .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
antrum.
43651.............. Laparoscopy, vagus nerve.. .................. T................. 0132 69.6652 $4,437.26 $1,239.22 $887.45
43652.............. Laparoscopy, vagus nerve.. .................. T................. 0132 69.6652 $4,437.26 $1,239.22 $887.45
43653.............. Laparoscopy, gastrostomy.. .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
43659.............. Laparoscope proc, stom.... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
43750.............. Place gastrostomy tube.... CH................ D................. ........... ........... ........... ........... ...........
43752.............. Nasal/orogastric w/stent.. .................. X................. 0272 1.3271 $84.53 $31.64 $16.91
43760.............. Change gastrostomy tube... .................. T................. 0121 3.2383 $206.26 $43.80 $41.25
43761.............. Reposition gastrostomy CH................ T................. 0141 8.5030 $541.59 $143.38 $108.32
tube.
43770.............. Lap place gastr adj device .................. C................. ........... ........... ........... ........... ...........
43771.............. Lap revise gastr adj .................. C................. ........... ........... ........... ........... ...........
device.
43772.............. Lap rmvl gastr adj device. .................. C................. ........... ........... ........... ........... ...........
43773.............. Lap replace gastr adj .................. C................. ........... ........... ........... ........... ...........
device.
43774.............. Lap rmvl gastr adj all .................. C................. ........... ........... ........... ........... ...........
parts.
43800.............. Reconstruction of pylorus. .................. C................. ........... ........... ........... ........... ...........
43810.............. Fusion of stomach and .................. C................. ........... ........... ........... ........... ...........
bowel.
43820.............. Fusion of stomach and .................. C................. ........... ........... ........... ........... ...........
bowel.
43825.............. Fusion of stomach and .................. C................. ........... ........... ........... ........... ...........
bowel.
43830.............. Place gastrostomy tube.... .................. T................. 0422 25.3233 $1,612.94 $448.81 $322.59
43831.............. Place gastrostomy tube.... .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43832.............. Place gastrostomy tube.... .................. C................. ........... ........... ........... ........... ...........
43840.............. Repair of stomach lesion.. .................. C................. ........... ........... ........... ........... ...........
43842.............. V-band gastroplasty....... .................. E................. ........... ........... ........... ........... ...........
43843.............. Gastroplasty w/o v-band... .................. C................. ........... ........... ........... ........... ...........
43845.............. Gastroplasty duodenal .................. C................. ........... ........... ........... ........... ...........
switch.
43846.............. Gastric bypass for obesity .................. C................. ........... ........... ........... ........... ...........
43847.............. Gastric bypass incl small .................. C................. ........... ........... ........... ........... ...........
i.
43848.............. Revision gastroplasty..... .................. C................. ........... ........... ........... ........... ...........
43850.............. Revise stomach-bowel .................. C................. ........... ........... ........... ........... ...........
fusion.
43855.............. Revise stomach-bowel .................. C................. ........... ........... ........... ........... ...........
fusion.
43860.............. Revise stomach-bowel .................. C................. ........... ........... ........... ........... ...........
fusion.
43865.............. Revise stomach-bowel .................. C................. ........... ........... ........... ........... ...........
fusion.
43870.............. Repair stomach opening.... .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
43880.............. Repair stomach-bowel .................. C................. ........... ........... ........... ........... ...........
fistula.
43881.............. Impl/redo electrd, antrum. .................. C................. ........... ........... ........... ........... ...........
43882.............. Revise/remove electrd .................. C................. ........... ........... ........... ........... ...........
antrum.
43886.............. Revise gastric port, open. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
43887.............. Remove gastric port, open. CH................ T................. 0135 4.5263 $288.30 ........... $57.66
43888.............. Change gastric port, open. CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
43999.............. Stomach surgery procedure. .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
44005.............. Freeing of bowel adhesion. .................. C................. ........... ........... ........... ........... ...........
44010.............. Incision of small bowel... .................. C................. ........... ........... ........... ........... ...........
44015.............. Insert needle cath bowel.. .................. C................. ........... ........... ........... ........... ...........
44020.............. Explore small intestine... .................. C................. ........... ........... ........... ........... ...........
44021.............. Decompress small bowel.... .................. C................. ........... ........... ........... ........... ...........
44025.............. Incision of large bowel... .................. C................. ........... ........... ........... ........... ...........
44050.............. Reduce bowel obstruction.. .................. C................. ........... ........... ........... ........... ...........
44055.............. Correct malrotation of .................. C................. ........... ........... ........... ........... ...........
bowel.
44100.............. Biopsy of bowel........... .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
44110.............. Excise intestine lesion(s) .................. C................. ........... ........... ........... ........... ...........
44111.............. Excision of bowel .................. C................. ........... ........... ........... ........... ...........
lesion(s).
44120.............. Removal of small intestine .................. C................. ........... ........... ........... ........... ...........
44121.............. Removal of small intestine .................. C................. ........... ........... ........... ........... ...........
44125.............. Removal of small intestine .................. C................. ........... ........... ........... ........... ...........
44126.............. Enterectomy w/o taper, .................. C................. ........... ........... ........... ........... ...........
cong.
44127.............. Enterectomy w/taper, cong. .................. C................. ........... ........... ........... ........... ...........
44128.............. Enterectomy cong, add-on.. .................. C................. ........... ........... ........... ........... ...........
44130.............. Bowel to bowel fusion..... .................. C................. ........... ........... ........... ........... ...........
44132.............. Enterectomy, cadaver donor .................. C................. ........... ........... ........... ........... ...........
44133.............. Enterectomy, live donor... .................. C................. ........... ........... ........... ........... ...........
44135.............. Intestine transplnt, .................. C................. ........... ........... ........... ........... ...........
cadaver.
44136.............. Intestine transplant, live .................. C................. ........... ........... ........... ........... ...........
44137.............. Remove intestinal .................. C................. ........... ........... ........... ........... ...........
allograft.
44139.............. Mobilization of colon..... .................. C................. ........... ........... ........... ........... ...........
44140.............. Partial removal of colon.. .................. C................. ........... ........... ........... ........... ...........
44141.............. Partial removal of colon.. .................. C................. ........... ........... ........... ........... ...........
[[Page 67044]]
44143.............. Partial removal of colon.. .................. C................. ........... ........... ........... ........... ...........
44144.............. Partial removal of colon.. .................. C................. ........... ........... ........... ........... ...........
44145.............. Partial removal of colon.. .................. C................. ........... ........... ........... ........... ...........
44146.............. Partial removal of colon.. .................. C................. ........... ........... ........... ........... ...........
44147.............. Partial removal of colon.. .................. C................. ........... ........... ........... ........... ...........
44150.............. Removal of colon.......... .................. C................. ........... ........... ........... ........... ...........
44151.............. Removal of colon/ileostomy .................. C................. ........... ........... ........... ........... ...........
44155.............. Removal of colon/ileostomy .................. C................. ........... ........... ........... ........... ...........
44156.............. Removal of colon/ileostomy .................. C................. ........... ........... ........... ........... ...........
44157.............. Colectomy w/ileoanal anast .................. C................. ........... ........... ........... ........... ...........
44158.............. Colectomy w/neo-rectum .................. C................. ........... ........... ........... ........... ...........
pouch.
44160.............. Removal of colon.......... .................. C................. ........... ........... ........... ........... ...........
44180.............. Lap, enterolysis.......... .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
44186.............. Lap, jejunostomy.......... .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
44187.............. Lap, ileo/jejuno-stomy.... .................. C................. ........... ........... ........... ........... ...........
44188.............. Lap, colostomy............ .................. C................. ........... ........... ........... ........... ...........
44202.............. Lap, enterectomy.......... .................. C................. ........... ........... ........... ........... ...........
44203.............. Lap resect s/intestine, .................. C................. ........... ........... ........... ........... ...........
addl.
44204.............. Laparo partial colectomy.. .................. C................. ........... ........... ........... ........... ...........
44205.............. Lap colectomy part w/ileum .................. C................. ........... ........... ........... ........... ...........
44206.............. Lap part colectomy w/stoma .................. T................. 0132 69.6652 $4,437.26 $1,239.22 $887.45
44207.............. L colectomy/ .................. T................. 0132 69.6652 $4,437.26 $1,239.22 $887.45
coloproctostomy.
44208.............. L colectomy/ .................. T................. 0132 69.6652 $4,437.26 $1,239.22 $887.45
coloproctostomy.
44210.............. Laparo total .................. C................. ........... ........... ........... ........... ...........
proctocolectomy.
44211.............. Lap colectomy w/ .................. C................. ........... ........... ........... ........... ...........
proctectomy.
44212.............. Laparo total .................. C................. ........... ........... ........... ........... ...........
proctocolectomy.
44213.............. Lap, mobil splenic fl add- .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
on.
44227.............. Lap, close enterostomy.... .................. C................. ........... ........... ........... ........... ...........
44238.............. Laparoscope proc, .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
intestine.
44300.............. Open bowel to skin........ .................. C................. ........... ........... ........... ........... ...........
44310.............. Ileostomy/jejunostomy..... .................. C................. ........... ........... ........... ........... ...........
44312.............. Revision of ileostomy..... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
44314.............. Revision of ileostomy..... .................. C................. ........... ........... ........... ........... ...........
44316.............. Devise bowel pouch........ .................. C................. ........... ........... ........... ........... ...........
44320.............. Colostomy................. .................. C................. ........... ........... ........... ........... ...........
44322.............. Colostomy with biopsies... .................. C................. ........... ........... ........... ........... ...........
44340.............. Revision of colostomy..... CH................ T................. 0137 20.2069 $1,287.06 ........... $257.41
44345.............. Revision of colostomy..... .................. C................. ........... ........... ........... ........... ...........
44346.............. Revision of colostomy..... .................. C................. ........... ........... ........... ........... ...........
44360.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44361.............. Small bowel endoscopy/ .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
biopsy.
44363.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44364.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44365.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44366.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44369.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44370.............. Small bowel endoscopy/ .................. T................. 0384 24.9814 $1,591.17 ........... $318.23
stent.
44372.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44373.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44376.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44377.............. Small bowel endoscopy/ .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
biopsy.
44378.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44379.............. S bowel endoscope w/stent. .................. T................. 0384 24.9814 $1,591.17 ........... $318.23
44380.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44382.............. Small bowel endoscopy..... .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
44383.............. Ileoscopy w/stent......... .................. T................. 0384 24.9814 $1,591.17 ........... $318.23
44385.............. Endoscopy of bowel pouch.. .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
44386.............. Endoscopy, bowel pouch/ .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
biop.
44388.............. Colonoscopy............... .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
44389.............. Colonoscopy with biopsy... .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
44390.............. Colonoscopy for foreign .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
body.
44391.............. Colonoscopy for bleeding.. .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
44392.............. Colonoscopy & polypectomy. .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
44393.............. Colonoscopy, lesion .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
removal.
44394.............. Colonoscopy w/snare....... .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
44397.............. Colonoscopy w/stent....... .................. T................. 0384 24.9814 $1,591.17 ........... $318.23
44500.............. Intro, gastrointestinal .................. T................. 0121 3.2383 $206.26 $43.80 $41.25
tube.
44602.............. Suture, small intestine... .................. C................. ........... ........... ........... ........... ...........
44603.............. Suture, small intestine... .................. C................. ........... ........... ........... ........... ...........
44604.............. Suture, large intestine... .................. C................. ........... ........... ........... ........... ...........
44605.............. Repair of bowel lesion.... .................. C................. ........... ........... ........... ........... ...........
44615.............. Intestinal stricturoplasty .................. C................. ........... ........... ........... ........... ...........
44620.............. Repair bowel opening...... .................. C................. ........... ........... ........... ........... ...........
44625.............. Repair bowel opening...... .................. C................. ........... ........... ........... ........... ...........
44626.............. Repair bowel opening...... .................. C................. ........... ........... ........... ........... ...........
44640.............. Repair bowel-skin fistula. .................. C................. ........... ........... ........... ........... ...........
44650.............. Repair bowel fistula...... .................. C................. ........... ........... ........... ........... ...........
44660.............. Repair bowel-bladder .................. C................. ........... ........... ........... ........... ...........
fistula.
44661.............. Repair bowel-bladder .................. C................. ........... ........... ........... ........... ...........
fistula.
44680.............. Surgical revision, .................. C................. ........... ........... ........... ........... ...........
intestine.
[[Page 67045]]
44700.............. Suspend bowel w/prosthesis .................. C................. ........... ........... ........... ........... ...........
44701.............. Intraop colon lavage add- .................. N................. ........... ........... ........... ........... ...........
on.
44715.............. Prepare donor intestine... .................. C................. ........... ........... ........... ........... ...........
44720.............. Prep donor intestine/ .................. C................. ........... ........... ........... ........... ...........
venous.
44721.............. Prep donor intestine/ .................. C................. ........... ........... ........... ........... ...........
artery.
44799.............. Unlisted procedure .................. T................. 0153 25.6947 $1,636.60 $397.95 $327.32
intestine.
44800.............. Excision of bowel pouch... .................. C................. ........... ........... ........... ........... ...........
44820.............. Excision of mesentery .................. C................. ........... ........... ........... ........... ...........
lesion.
44850.............. Repair of mesentery....... .................. C................. ........... ........... ........... ........... ...........
44899.............. Bowel surgery procedure... .................. C................. ........... ........... ........... ........... ...........
44900.............. Drain app abscess, open... .................. C................. ........... ........... ........... ........... ...........
44901.............. Drain app abscess, percut. .................. T................. 0037 13.5764 $864.74 $228.76 $172.95
44950.............. Appendectomy.............. .................. C................. ........... ........... ........... ........... ...........
44955.............. Appendectomy add-on....... .................. C................. ........... ........... ........... ........... ...........
44960.............. Appendectomy.............. .................. C................. ........... ........... ........... ........... ...........
44970.............. Laparoscopy, appendectomy. .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
44979.............. Laparoscope proc, app..... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
45000.............. Drainage of pelvic abscess CH................ T................. 0155 10.9132 $695.11 ........... $139.02
45005.............. Drainage of rectal abscess .................. T................. 0155 10.9132 $695.11 ........... $139.02
45020.............. Drainage of rectal abscess .................. T................. 0155 10.9132 $695.11 ........... $139.02
45100.............. Biopsy of rectum.......... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
45108.............. Removal of anorectal .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
lesion.
45110.............. Removal of rectum......... .................. C................. ........... ........... ........... ........... ...........
45111.............. Partial removal of rectum. .................. C................. ........... ........... ........... ........... ...........
45112.............. Removal of rectum......... .................. C................. ........... ........... ........... ........... ...........
45113.............. Partial proctectomy....... .................. C................. ........... ........... ........... ........... ...........
45114.............. Partial removal of rectum. .................. C................. ........... ........... ........... ........... ...........
45116.............. Partial removal of rectum. .................. C................. ........... ........... ........... ........... ...........
45119.............. Remove rectum w/reservoir. .................. C................. ........... ........... ........... ........... ...........
45120.............. Removal of rectum......... .................. C................. ........... ........... ........... ........... ...........
45121.............. Removal of rectum and .................. C................. ........... ........... ........... ........... ...........
colon.
45123.............. Partial proctectomy....... .................. C................. ........... ........... ........... ........... ...........
45126.............. Pelvic exenteration....... .................. C................. ........... ........... ........... ........... ...........
45130.............. Excision of rectal .................. C................. ........... ........... ........... ........... ...........
prolapse.
45135.............. Excision of rectal .................. C................. ........... ........... ........... ........... ...........
prolapse.
45136.............. Excise ileoanal reservior. .................. C................. ........... ........... ........... ........... ...........
45150.............. Excision of rectal .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
stricture.
45160.............. Excision of rectal lesion. .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
45170.............. Excision of rectal lesion. .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
45190.............. Destruction, rectal tumor. .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
45300.............. Proctosigmoidoscopy dx.... .................. T................. 0146 5.0972 $324.66 ........... $64.93
45303.............. Proctosigmoidoscopy dilate .................. T................. 0147 8.7031 $554.34 ........... $110.87
45305.............. Proctosigmoidoscopy w/bx.. .................. T................. 0147 8.7031 $554.34 ........... $110.87
45307.............. Proctosigmoidoscopy fb.... .................. T................. 0428 21.4632 $1,367.08 ........... $273.42
45308.............. Proctosigmoidoscopy .................. T................. 0147 8.7031 $554.34 ........... $110.87
removal.
45309.............. Proctosigmoidoscopy .................. T................. 0147 8.7031 $554.34 ........... $110.87
removal.
45315.............. Proctosigmoidoscopy .................. T................. 0147 8.7031 $554.34 ........... $110.87
removal.
45317.............. Proctosigmoidoscopy bleed. .................. T................. 0147 8.7031 $554.34 ........... $110.87
45320.............. Proctosigmoidoscopy ablate .................. T................. 0428 21.4632 $1,367.08 ........... $273.42
45321.............. Proctosigmoidoscopy volvul .................. T................. 0428 21.4632 $1,367.08 ........... $273.42
45327.............. Proctosigmoidoscopy w/ .................. T................. 0384 24.9814 $1,591.17 ........... $318.23
stent.
45330.............. Diagnostic sigmoidoscopy.. .................. T................. 0146 5.0972 $324.66 ........... $64.93
45331.............. Sigmoidoscopy and biopsy.. .................. T................. 0146 5.0972 $324.66 ........... $64.93
45332.............. Sigmoidoscopy w/fb removal .................. T................. 0146 5.0972 $324.66 ........... $64.93
45333.............. Sigmoidoscopy & .................. T................. 0147 8.7031 $554.34 ........... $110.87
polypectomy.
45334.............. Sigmoidoscopy for bleeding .................. T................. 0147 8.7031 $554.34 ........... $110.87
45335.............. Sigmoidoscopy w/submuc inj .................. T................. 0146 5.0972 $324.66 ........... $64.93
45337.............. Sigmoidoscopy & decompress .................. T................. 0146 5.0972 $324.66 ........... $64.93
45338.............. Sigmoidoscopy w/tumr .................. T................. 0147 8.7031 $554.34 ........... $110.87
remove.
45339.............. Sigmoidoscopy w/ablate .................. T................. 0147 8.7031 $554.34 ........... $110.87
tumr.
45340.............. Sig w/balloon dilation.... .................. T................. 0147 8.7031 $554.34 ........... $110.87
45341.............. Sigmoidoscopy w/ultrasound .................. T................. 0147 8.7031 $554.34 ........... $110.87
45342.............. Sigmoidoscopy w/us guide .................. T................. 0147 8.7031 $554.34 ........... $110.87
bx.
45345.............. Sigmoidoscopy w/stent..... .................. T................. 0384 24.9814 $1,591.17 ........... $318.23
45355.............. Surgical colonoscopy...... .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
45378.............. Diagnostic colonoscopy.... .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
45379.............. Colonoscopy w/fb removal.. .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
45380.............. Colonoscopy and biopsy.... .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
45381.............. Colonoscopy, submucous inj .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
45382.............. Colonoscopy/control .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
bleeding.
45383.............. Lesion removal colonoscopy .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
45384.............. Lesion remove colonoscopy. .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
45385.............. Lesion removal colonoscopy .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
45386.............. Colonoscopy dilate .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
stricture.
45387.............. Colonoscopy w/stent....... .................. T................. 0384 24.9814 $1,591.17 ........... $318.23
45391.............. Colonoscopy w/endoscope us .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
45392.............. Colonoscopy w/endoscopic .................. T................. 0143 8.8486 $563.60 $186.06 $112.72
fnb.
45395.............. Lap, removal of rectum.... .................. C................. ........... ........... ........... ........... ...........
45397.............. Lap, remove rectum w/pouch .................. C................. ........... ........... ........... ........... ...........
45400.............. Laparoscopic proc......... .................. C................. ........... ........... ........... ........... ...........
[[Page 67046]]
45402.............. Lap proctopexy w/sig .................. C................. ........... ........... ........... ........... ...........
resect.
45499.............. Laparoscope proc, rectum.. .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
45500.............. Repair of rectum.......... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
45505.............. Repair of rectum.......... .................. T................. 0150 30.1606 $1,921.05 $437.12 $384.21
45520.............. Treatment of rectal CH................ T................. 0013 0.7930 $50.51 ........... $10.10
prolapse.
45540.............. Correct rectal prolapse... .................. C................. ........... ........... ........... ........... ...........
45541.............. Correct rectal prolapse... .................. T................. 0150 30.1606 $1,921.05 $437.12 $384.21
45550.............. Repair rectum/remove .................. C................. ........... ........... ........... ........... ...........
sigmoid.
45560.............. Repair of rectocele....... .................. T................. 0150 30.1606 $1,921.05 $437.12 $384.21
45562.............. Exploration/repair of .................. C................. ........... ........... ........... ........... ...........
rectum.
45563.............. Exploration/repair of .................. C................. ........... ........... ........... ........... ...........
rectum.
45800.............. Repair rect/bladder .................. C................. ........... ........... ........... ........... ...........
fistula.
45805.............. Repair fistula w/colostomy .................. C................. ........... ........... ........... ........... ...........
45820.............. Repair rectourethral .................. C................. ........... ........... ........... ........... ...........
fistula.
45825.............. Repair fistula w/colostomy .................. C................. ........... ........... ........... ........... ...........
45900.............. Reduction of rectal .................. T................. 0148 4.7935 $305.32 ........... $61.06
prolapse.
45905.............. Dilation of anal sphincter .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
45910.............. Dilation of rectal .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
narrowing.
45915.............. Remove rectal obstruction. CH................ T................. 0155 10.9132 $695.11 ........... $139.02
45990.............. Surg dx exam, anorectal... CH................ T................. 0149 22.7451 $1,448.73 $293.06 $289.75
45999.............. Rectum surgery procedure.. .................. T................. 0148 4.7935 $305.32 ........... $61.06
46020.............. Placement of seton........ .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46030.............. Removal of rectal marker.. .................. T................. 0148 4.7935 $305.32 ........... $61.06
46040.............. Incision of rectal abscess .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46045.............. Incision of rectal abscess .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46050.............. Incision of anal abscess.. CH................ T................. 0155 10.9132 $695.11 ........... $139.02
46060.............. Incision of rectal abscess .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46070.............. Incision of anal septum... .................. T................. 0155 10.9132 $695.11 ........... $139.02
46080.............. Incision of anal sphincter .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46083.............. Incise external hemorrhoid .................. T................. 0164 2.0077 $127.88 ........... $25.58
46200.............. Removal of anal fissure... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46210.............. Removal of anal crypt..... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46211.............. Removal of anal crypts.... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46220.............. Removal of anal tag....... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46221.............. Ligation of hemorrhoid(s). .................. T................. 0148 4.7935 $305.32 ........... $61.06
46230.............. Removal of anal tags...... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46250.............. Hemorrhoidectomy.......... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46255.............. Hemorrhoidectomy.......... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46257.............. Remove hemorrhoids & .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
fissure.
46258.............. Remove hemorrhoids & .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
fistula.
46260.............. Hemorrhoidectomy.......... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46261.............. Remove hemorrhoids & .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
fissure.
46262.............. Remove hemorrhoids & .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
fistula.
46270.............. Removal of anal fistula... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46275.............. Removal of anal fistula... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46280.............. Removal of anal fistula... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46285.............. Removal of anal fistula... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46288.............. Repair anal fistula....... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46320.............. Removal of hemorrhoid clot CH................ T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46500.............. Injection into .................. T................. 0155 10.9132 $695.11 ........... $139.02
hemorrhoid(s).
46505.............. Chemodenervation anal musc .................. T................. 0148 4.7935 $305.32 ........... $61.06
46600.............. Diagnostic anoscopy....... .................. X................. 0340 0.6310 $40.19 ........... $8.04
46604.............. Anoscopy and dilation..... .................. T................. 0147 8.7031 $554.34 ........... $110.87
46606.............. Anoscopy and biopsy....... .................. T................. 0146 5.0972 $324.66 ........... $64.93
46608.............. Anoscopy, remove for body. .................. T................. 0147 8.7031 $554.34 ........... $110.87
46610.............. Anoscopy, remove lesion... .................. T................. 0428 21.4632 $1,367.08 ........... $273.42
46611.............. Anoscopy.................. .................. T................. 0147 8.7031 $554.34 ........... $110.87
46612.............. Anoscopy, remove lesions.. .................. T................. 0428 21.4632 $1,367.08 ........... $273.42
46614.............. Anoscopy, control bleeding .................. T................. 0146 5.0972 $324.66 ........... $64.93
46615.............. Anoscopy.................. .................. T................. 0428 21.4632 $1,367.08 ........... $273.42
46700.............. Repair of anal stricture.. .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46705.............. Repair of anal stricture.. .................. C................. ........... ........... ........... ........... ...........
46706.............. Repr of anal fistula w/ .................. T................. 0150 30.1606 $1,921.05 $437.12 $384.21
glue.
46710.............. Repr per/vag pouch sngl .................. C................. ........... ........... ........... ........... ...........
proc.
46712.............. Repr per/vag pouch dbl .................. C................. ........... ........... ........... ........... ...........
proc.
46715.............. Rep perf anoper fistu..... .................. C................. ........... ........... ........... ........... ...........
46716.............. Rep perf anoper/vestib .................. C................. ........... ........... ........... ........... ...........
fistu.
46730.............. Construction of absent .................. C................. ........... ........... ........... ........... ...........
anus.
46735.............. Construction of absent .................. C................. ........... ........... ........... ........... ...........
anus.
46740.............. Construction of absent .................. C................. ........... ........... ........... ........... ...........
anus.
46742.............. Repair of imperforated .................. C................. ........... ........... ........... ........... ...........
anus.
46744.............. Repair of cloacal anomaly. .................. C................. ........... ........... ........... ........... ...........
46746.............. Repair of cloacal anomaly. .................. C................. ........... ........... ........... ........... ...........
46748.............. Repair of cloacal anomaly. .................. C................. ........... ........... ........... ........... ...........
46750.............. Repair of anal sphincter.. CH................ T................. 0150 30.1606 $1,921.05 $437.12 $384.21
46751.............. Repair of anal sphincter.. .................. C................. ........... ........... ........... ........... ...........
46753.............. Reconstruction of anus.... .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46754.............. Removal of suture from .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
anus.
46760.............. Repair of anal sphincter.. CH................ T................. 0150 30.1606 $1,921.05 $437.12 $384.21
46761.............. Repair of anal sphincter.. CH................ T................. 0150 30.1606 $1,921.05 $437.12 $384.21
[[Page 67047]]
46762.............. Implant artificial CH................ T................. 0150 30.1606 $1,921.05 $437.12 $384.21
sphincter.
46900.............. Destruction, anal .................. T................. 0016 2.6604 $169.45 ........... $33.89
lesion(s).
46910.............. Destruction, anal .................. T................. 0017 19.9041 $1,267.77 ........... $253.55
lesion(s).
46916.............. Cryosurgery, anal CH................ T................. 0015 1.4595 $92.96 ........... $18.59
lesion(s).
46917.............. Laser surgery, anal CH................ T................. 0017 19.9041 $1,267.77 ........... $253.55
lesions.
46922.............. Excision of anal lesion(s) CH................ T................. 0017 19.9041 $1,267.77 ........... $253.55
46924.............. Destruction, anal CH................ T................. 0017 19.9041 $1,267.77 ........... $253.55
lesion(s).
46934.............. Destruction of hemorrhoids .................. T................. 0155 10.9132 $695.11 ........... $139.02
46935.............. Destruction of hemorrhoids .................. T................. 0155 10.9132 $695.11 ........... $139.02
46936.............. Destruction of hemorrhoids .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46937.............. Cryotherapy of rectal .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
lesion.
46938.............. Cryotherapy of rectal .................. T................. 0150 30.1606 $1,921.05 $437.12 $384.21
lesion.
46940.............. Treatment of anal fissure. .................. T................. 0149 22.7451 $1,448.73 $293.06 $289.75
46942.............. Treatment of anal fissure. .................. T................. 0148 4.7935 $305.32 ........... $61.06
46945.............. Ligation of hemorrhoids... .................. T................. 0155 10.9132 $695.11 ........... $139.02
46946.............. Ligation of hemorrhoids... .................. T................. 0155 10.9132 $695.11 ........... $139.02
46947.............. Hemorrhoidopexy by .................. T................. 0150 30.1606 $1,921.05 $437.12 $384.21
stapling.
46999.............. Anus surgery procedure.... .................. T................. 0148 4.7935 $305.32 ........... $61.06
47000.............. Needle biopsy of liver.... .................. T................. 0685 9.3354 $594.61 ........... $118.92
47001.............. Needle biopsy, liver add- .................. N................. ........... ........... ........... ........... ...........
on.
47010.............. Open drainage, liver .................. C................. ........... ........... ........... ........... ...........
lesion.
47011.............. Percut drain, liver lesion .................. T................. 0037 13.5764 $864.74 $228.76 $172.95
47015.............. Inject/aspirate liver cyst .................. C................. ........... ........... ........... ........... ...........
47100.............. Wedge biopsy of liver..... .................. C................. ........... ........... ........... ........... ...........
47120.............. Partial removal of liver.. .................. C................. ........... ........... ........... ........... ...........
47122.............. Extensive removal of liver .................. C................. ........... ........... ........... ........... ...........
47125.............. Partial removal of liver.. .................. C................. ........... ........... ........... ........... ...........
47130.............. Partial removal of liver.. .................. C................. ........... ........... ........... ........... ...........
47133.............. Removal of donor liver.... .................. C................. ........... ........... ........... ........... ...........
47135.............. Transplantation of liver.. .................. C................. ........... ........... ........... ........... ...........
47136.............. Transplantation of liver.. .................. C................. ........... ........... ........... ........... ...........
47140.............. Partial removal, donor .................. C................. ........... ........... ........... ........... ...........
liver.
47141.............. Partial removal, donor .................. C................. ........... ........... ........... ........... ...........
liver.
47142.............. Partial removal, donor .................. C................. ........... ........... ........... ........... ...........
liver.
47143.............. Prep donor liver, whole... .................. C................. ........... ........... ........... ........... ...........
47144.............. Prep donor liver, 3- .................. C................. ........... ........... ........... ........... ...........
segment.
47145.............. Prep donor liver, lobe .................. C................. ........... ........... ........... ........... ...........
split.
47146.............. Prep donor liver/venous... .................. C................. ........... ........... ........... ........... ...........
47147.............. Prep donor liver/arterial. .................. C................. ........... ........... ........... ........... ...........
47300.............. Surgery for liver lesion.. .................. C................. ........... ........... ........... ........... ...........
47350.............. Repair liver wound........ .................. C................. ........... ........... ........... ........... ...........
47360.............. Repair liver wound........ .................. C................. ........... ........... ........... ........... ...........
47361.............. Repair liver wound........ .................. C................. ........... ........... ........... ........... ...........
47362.............. Repair liver wound........ .................. C................. ........... ........... ........... ........... ...........
47370.............. Laparo ablate liver tumor .................. T................. 0132 69.6652 $4,437.26 $1,239.22 $887.45
rf.
47371.............. Laparo ablate liver .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
cryosurg.
47379.............. Laparoscope procedure, .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
liver.
47380.............. Open ablate liver tumor rf .................. C................. ........... ........... ........... ........... ...........
47381.............. Open ablate liver tumor .................. C................. ........... ........... ........... ........... ...........
cryo.
47382.............. Percut ablate liver rf.... .................. T................. 0423 42.9980 $2,738.71 ........... $547.74
47399.............. Liver surgery procedure... .................. T................. 0004 4.3270 $275.60 ........... $55.12
47400.............. Incision of liver duct.... .................. C................. ........... ........... ........... ........... ...........
47420.............. Incision of bile duct..... .................. C................. ........... ........... ........... ........... ...........
47425.............. Incision of bile duct..... .................. C................. ........... ........... ........... ........... ...........
47460.............. Incise bile duct sphincter .................. C................. ........... ........... ........... ........... ...........
47480.............. Incision of gallbladder... .................. C................. ........... ........... ........... ........... ...........
47490.............. Incision of gallbladder... .................. T................. 0152 28.6884 $1,827.28 ........... $365.46
47500.............. Injection for liver x-rays .................. N................. ........... ........... ........... ........... ...........
47505.............. Injection for liver x-rays .................. N................. ........... ........... ........... ........... ...........
47510.............. Insert catheter, bile duct .................. T................. 0152 28.6884 $1,827.28 ........... $365.46
47511.............. Insert bile duct drain.... .................. T................. 0152 28.6884 $1,827.28 ........... $365.46
47525.............. Change bile duct catheter. .................. T................. 0427 15.3545 $977.99 ........... $195.60
47530.............. Revise/reinsert bile tube. .................. T................. 0427 15.3545 $977.99 ........... $195.60
47550.............. Bile duct endoscopy add-on .................. C................. ........... ........... ........... ........... ...........
47552.............. Biliary endoscopy thru .................. T................. 0152 28.6884 $1,827.28 ........... $365.46
skin.
47553.............. Biliary endoscopy thru .................. T................. 0152 28.6884 $1,827.28 ........... $365.46
skin.
47554.............. Biliary endoscopy thru .................. T................. 0152 28.6884 $1,827.28 ........... $365.46
skin.
47555.............. Biliary endoscopy thru .................. T................. 0152 28.6884 $1,827.28 ........... $365.46
skin.
47556.............. Biliary endoscopy thru .................. T................. 0152 28.6884 $1,827.28 ........... $365.46
skin.
47560.............. Laparoscopy w/cholangio... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
47561.............. Laparo w/cholangio/biopsy. .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
47562.............. Laparoscopic .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
cholecystectomy.
47563.............. Laparo cholecystectomy/ .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
graph.
47564.............. Laparo cholecystectomy/ .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
explr.
47570.............. Laparo .................. C................. ........... ........... ........... ........... ...........
cholecystoenterostomy.
47579.............. Laparoscope proc, biliary. .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
47600.............. Removal of gallbladder.... .................. C................. ........... ........... ........... ........... ...........
47605.............. Removal of gallbladder.... .................. C................. ........... ........... ........... ........... ...........
47610.............. Removal of gallbladder.... .................. C................. ........... ........... ........... ........... ...........
47612.............. Removal of gallbladder.... .................. C................. ........... ........... ........... ........... ...........
[[Page 67048]]
47620.............. Removal of gallbladder.... .................. C................. ........... ........... ........... ........... ...........
47630.............. Remove bile duct stone.... .................. T................. 0152 28.6884 $1,827.28 ........... $365.46
47700.............. Exploration of bile ducts. .................. C................. ........... ........... ........... ........... ...........
47701.............. Bile duct revision........ .................. C................. ........... ........... ........... ........... ...........
47711.............. Excision of bile duct .................. C................. ........... ........... ........... ........... ...........
tumor.
47712.............. Excision of bile duct .................. C................. ........... ........... ........... ........... ...........
tumor.
47715.............. Excision of bile duct cyst .................. C................. ........... ........... ........... ........... ...........
47719.............. Fusion of bile duct cyst.. CH................ D................. ........... ........... ........... ........... ...........
47720.............. Fuse gallbladder & bowel.. .................. C................. ........... ........... ........... ........... ...........
47721.............. Fuse upper gi structures.. .................. C................. ........... ........... ........... ........... ...........
47740.............. Fuse gallbladder & bowel.. .................. C................. ........... ........... ........... ........... ...........
47741.............. Fuse gallbladder & bowel.. .................. C................. ........... ........... ........... ........... ...........
47760.............. Fuse bile ducts and bowel. .................. C................. ........... ........... ........... ........... ...........
47765.............. Fuse liver ducts & bowel.. .................. C................. ........... ........... ........... ........... ...........
47780.............. Fuse bile ducts and bowel. .................. C................. ........... ........... ........... ........... ...........
47785.............. Fuse bile ducts and bowel. .................. C................. ........... ........... ........... ........... ...........
47800.............. Reconstruction of bile .................. C................. ........... ........... ........... ........... ...........
ducts.
47801.............. Placement, bile duct .................. C................. ........... ........... ........... ........... ...........
support.
47802.............. Fuse liver duct & .................. C................. ........... ........... ........... ........... ...........
intestine.
47900.............. Suture bile duct injury... .................. C................. ........... ........... ........... ........... ...........
47999.............. Bile tract surgery .................. T................. 0152 28.6884 $1,827.28 ........... $365.46
procedure.
48000.............. Drainage of abdomen....... .................. C................. ........... ........... ........... ........... ...........
48001.............. Placement of drain, .................. C................. ........... ........... ........... ........... ...........
pancreas.
48020.............. Removal of pancreatic .................. C................. ........... ........... ........... ........... ...........
stone.
48100.............. Biopsy of pancreas, open.. .................. C................. ........... ........... ........... ........... ...........
48102.............. Needle biopsy, pancreas... .................. T................. 0685 9.3354 $594.61 ........... $118.92
48105.............. Resect/debride pancreas... .................. C................. ........... ........... ........... ........... ...........
48120.............. Removal of pancreas lesion .................. C................. ........... ........... ........... ........... ...........
48140.............. Partial removal of .................. C................. ........... ........... ........... ........... ...........
pancreas.
48145.............. Partial removal of .................. C................. ........... ........... ........... ........... ...........
pancreas.
48146.............. Pancreatectomy............ .................. C................. ........... ........... ........... ........... ...........
48148.............. Removal of pancreatic duct .................. C................. ........... ........... ........... ........... ...........
48150.............. Partial removal of .................. C................. ........... ........... ........... ........... ...........
pancreas.
48152.............. Pancreatectomy............ .................. C................. ........... ........... ........... ........... ...........
48153.............. Pancreatectomy............ .................. C................. ........... ........... ........... ........... ...........
48154.............. Pancreatectomy............ .................. C................. ........... ........... ........... ........... ...........
48155.............. Removal of pancreas....... .................. C................. ........... ........... ........... ........... ...........
48160.............. Pancreas removal/ .................. E................. ........... ........... ........... ........... ...........
transplant.
48400.............. Injection, intraop add-on. .................. C................. ........... ........... ........... ........... ...........
48500.............. Surgery of pancreatic cyst .................. C................. ........... ........... ........... ........... ...........
48510.............. Drain pancreatic .................. C................. ........... ........... ........... ........... ...........
pseudocyst.
48511.............. Drain pancreatic .................. T................. 0037 13.5764 $864.74 $228.76 $172.95
pseudocyst.
48520.............. Fuse pancreas cyst and .................. C................. ........... ........... ........... ........... ...........
bowel.
48540.............. Fuse pancreas cyst and .................. C................. ........... ........... ........... ........... ...........
bowel.
48545.............. Pancreatorrhaphy.......... .................. C................. ........... ........... ........... ........... ...........
48547.............. Duodenal exclusion........ .................. C................. ........... ........... ........... ........... ...........
48548.............. Fuse pancreas and bowel... .................. C................. ........... ........... ........... ........... ...........
48550.............. Donor pancreatectomy...... .................. E................. ........... ........... ........... ........... ...........
48551.............. Prep donor pancreas....... .................. C................. ........... ........... ........... ........... ...........
48552.............. Prep donor pancreas/venous .................. C................. ........... ........... ........... ........... ...........
48554.............. Transpl allograft pancreas .................. C................. ........... ........... ........... ........... ...........
48556.............. Removal, allograft .................. C................. ........... ........... ........... ........... ...........
pancreas.
48999.............. Pancreas surgery procedure .................. T................. 0004 4.3270 $275.60 ........... $55.12
49000.............. Exploration of abdomen.... .................. C................. ........... ........... ........... ........... ...........
49002.............. Reopening of abdomen...... .................. C................. ........... ........... ........... ........... ...........
49010.............. Exploration behind abdomen .................. C................. ........... ........... ........... ........... ...........
49020.............. Drain abdominal abscess... .................. C................. ........... ........... ........... ........... ...........
49021.............. Drain abdominal abscess... .................. T................. 0037 13.5764 $864.74 $228.76 $172.95
49040.............. Drain, open, abdom abscess .................. C................. ........... ........... ........... ........... ...........
49041.............. Drain, percut, abdom .................. T................. 0037 13.5764 $864.74 $228.76 $172.95
abscess.
49060.............. Drain, open, retrop .................. C................. ........... ........... ........... ........... ...........
abscess.
49061.............. Drain, percut, retroper .................. T................. 0037 13.5764 $864.74 $228.76 $172.95
absc.
49062.............. Drain to peritoneal cavity .................. C................. ........... ........... ........... ........... ...........
49080.............. Puncture, peritoneal .................. T................. 0070 5.2024 $331.36 ........... $66.27
cavity.
49081.............. Removal of abdominal fluid .................. T................. 0070 5.2024 $331.36 ........... $66.27
49180.............. Biopsy, abdominal mass.... .................. T................. 0685 9.3354 $594.61 ........... $118.92
49200.............. Removal of abdominal CH................ D................. ........... ........... ........... ........... ...........
lesion.
49201.............. Remove abdom lesion, CH................ D................. ........... ........... ........... ........... ...........
complex.
49203.............. Exc abd tum 5 cm or less.. NI................ C................. ........... ........... ........... ........... ...........
49204.............. Exc abd tum over 5 cm..... NI................ C................. ........... ........... ........... ........... ...........
49205.............. Exc abd tum over 10 cm.... NI................ C................. ........... ........... ........... ........... ...........
49215.............. Excise sacral spine tumor. .................. C................. ........... ........... ........... ........... ...........
49220.............. Multiple surgery, abdomen. .................. C................. ........... ........... ........... ........... ...........
49250.............. Excision of umbilicus..... .................. T................. 0153 25.6947 $1,636.60 $397.95 $327.32
49255.............. Removal of omentum........ .................. C................. ........... ........... ........... ........... ...........
49320.............. Diag laparo separate proc. .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
49321.............. Laparoscopy, biopsy....... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
49322.............. Laparoscopy, aspiration... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
49323.............. Laparo drain lymphocele... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
49324.............. Lap insertion perm ip cath .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
[[Page 67049]]
49325.............. Lap revision perm ip cath. .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
49326.............. Lap w/omentopexy add-on... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
49329.............. Laparo proc, abdm/per/ .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
oment.
49400.............. Air injection into abdomen .................. N................. ........... ........... ........... ........... ...........
49402.............. Remove foreign body, .................. T................. 0153 25.6947 $1,636.60 $397.95 $327.32
adbomen.
49419.............. Insrt abdom cath for .................. T................. 0115 29.6965 $1,891.49 ........... $378.30
chemotx.
49420.............. Insert abdom drain, temp.. .................. T................. 0652 30.7096 $1,956.02 ........... $391.20
49421.............. Insert abdom drain, perm.. .................. T................. 0652 30.7096 $1,956.02 ........... $391.20
49422.............. Remove perm cannula/ .................. T................. 0105 23.9802 $1,527.39 ........... $305.48
catheter.
49423.............. Exchange drainage catheter .................. T................. 0427 15.3545 $977.99 ........... $195.60
49424.............. Assess cyst, contrast .................. N................. ........... ........... ........... ........... ...........
inject.
49425.............. Insert abdomen-venous .................. C................. ........... ........... ........... ........... ...........
drain.
49426.............. Revise abdomen-venous .................. T................. 0153 25.6947 $1,636.60 $397.95 $327.32
shunt.
49427.............. Injection, abdominal shunt .................. N................. ........... ........... ........... ........... ...........
49428.............. Ligation of shunt......... .................. C................. ........... ........... ........... ........... ...........
49429.............. Removal of shunt.......... .................. T................. 0105 23.9802 $1,527.39 ........... $305.48
49435.............. Insert subq exten to ip .................. T................. 0427 15.3545 $977.99 ........... $195.60
cath.
49436.............. Embedded ip cath exit-site .................. T................. 0427 15.3545 $977.99 ........... $195.60
49440.............. Place gastrostomy tube NI................ T................. 0141 8.5030 $541.59 $143.38 $108.32
perc.
49441.............. Place duod/jej tube perc.. NI................ T................. 0141 8.5030 $541.59 $143.38 $108.32
49442.............. Place cecostomy tube perc. NI................ T................. 0155 10.9132 $695.11 ........... $139.02
49446.............. Change g-tube to g-j perc. NI................ T................. 0141 8.5030 $541.59 $143.38 $108.32
49450.............. Replace g/c tube perc..... NI................ T................. 0121 3.2383 $206.26 $43.80 $41.25
49451.............. Replace duod/jej tube perc NI................ T................. 0121 3.2383 $206.26 $43.80 $41.25
49452.............. Replace g-j tube perc..... NI................ T................. 0121 3.2383 $206.26 $43.80 $41.25
49460.............. Fix g/colon tube w/device. NI................ T................. 0121 3.2383 $206.26 $43.80 $41.25
49465.............. Fluoro exam of g/colon NI................ Q................. 0276 1.3834 $88.11 $34.97 $17.62
tube.
49491.............. Rpr hern preemie reduc.... .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
49492.............. Rpr ing hern premie, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
blocked.
49495.............. Rpr ing hernia baby, reduc .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
49496.............. Rpr ing hernia baby, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
blocked.
49500.............. Rpr ing hernia, init, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
reduce.
49501.............. Rpr ing hernia, init .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
blocked.
49505.............. Prp i/hern init reduc >5 .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
yr.
49507.............. Prp i/hern init block >5 .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
yr.
49520.............. Rerepair ing hernia, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
reduce.
49521.............. Rerepair ing hernia, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
blocked.
49525.............. Repair ing hernia, sliding .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
49540.............. Repair lumbar hernia...... .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
49550.............. Rpr rem hernia, init, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
reduce.
49553.............. Rpr fem hernia, init .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
blocked.
49555.............. Rerepair fem hernia, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
reduce.
49557.............. Rerepair fem hernia, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
blocked.
49560.............. Rpr ventral hern init, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
reduc.
49561.............. Rpr ventral hern init, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
block.
49565.............. Rerepair ventrl hern, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
reduce.
49566.............. Rerepair ventrl hern, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
block.
49568.............. Hernia repair w/mesh...... .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
49570.............. Rpr epigastric hern, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
reduce.
49572.............. Rpr epigastric hern, .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
blocked.
49580.............. Rpr umbil hern, reduc < 5 .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
yr.
49582.............. Rpr umbil hern, block < 5 .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
yr.
49585.............. Rpr umbil hern, reduc > 5 .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
yr.
49587.............. Rpr umbil hern, block > 5 .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
yr.
49590.............. Repair spigelian hernia... .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
49600.............. Repair umbilical lesion... .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
49605.............. Repair umbilical lesion... .................. C................. ........... ........... ........... ........... ...........
49606.............. Repair umbilical lesion... .................. C................. ........... ........... ........... ........... ...........
49610.............. Repair umbilical lesion... .................. C................. ........... ........... ........... ........... ...........
49611.............. Repair umbilical lesion... .................. C................. ........... ........... ........... ........... ...........
49650.............. Laparo hernia repair .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
initial.
49651.............. Laparo hernia repair recur .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
49659.............. Laparo proc, hernia repair .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
49900.............. Repair of abdominal wall.. .................. C................. ........... ........... ........... ........... ...........
49904.............. Omental flap, extra-abdom. .................. C................. ........... ........... ........... ........... ...........
49905.............. Omental flap, intra-abdom. .................. C................. ........... ........... ........... ........... ...........
49906.............. Free omental flap, .................. C................. ........... ........... ........... ........... ...........
microvasc.
49999.............. Abdomen surgery procedure. .................. T................. 0153 25.6947 $1,636.60 $397.95 $327.32
50010.............. Exploration of kidney..... .................. C................. ........... ........... ........... ........... ...........
50020.............. Renal abscess, open drain. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
50021.............. Renal abscess, percut .................. T................. 0037 13.5764 $864.74 $228.76 $172.95
drain.
50040.............. Drainage of kidney........ .................. C................. ........... ........... ........... ........... ...........
50045.............. Exploration of kidney..... .................. C................. ........... ........... ........... ........... ...........
5005F.............. Pt counsld on exam for .................. M................. ........... ........... ........... ........... ...........
moles.
50060.............. Removal of kidney stone... .................. C................. ........... ........... ........... ........... ...........
50065.............. Incision of kidney........ .................. C................. ........... ........... ........... ........... ...........
50070.............. Incision of kidney........ .................. C................. ........... ........... ........... ........... ...........
50075.............. Removal of kidney stone... .................. C................. ........... ........... ........... ........... ...........
50080.............. Removal of kidney stone... .................. T................. 0429 45.2042 $2,879.24 ........... $575.85
50081.............. Removal of kidney stone... .................. T................. 0429 45.2042 $2,879.24 ........... $575.85
[[Page 67050]]
50100.............. Revise kidney blood .................. C................. ........... ........... ........... ........... ...........
vessels.
5010F.............. Macul+ fndngs to dr mng dm .................. M................. ........... ........... ........... ........... ...........
50120.............. Exploration of kidney..... .................. C................. ........... ........... ........... ........... ...........
50125.............. Explore and drain kidney.. .................. C................. ........... ........... ........... ........... ...........
50130.............. Removal of kidney stone... .................. C................. ........... ........... ........... ........... ...........
50135.............. Exploration of kidney..... .................. C................. ........... ........... ........... ........... ...........
5015F.............. Doc fx & test/txmnt for op .................. M................. ........... ........... ........... ........... ...........
50200.............. Biopsy of kidney.......... .................. T................. 0685 9.3354 $594.61 ........... $118.92
50205.............. Biopsy of kidney.......... .................. C................. ........... ........... ........... ........... ...........
5020F.............. Txmnts 2 main Dr by 1 mon. NI................ M................. ........... ........... ........... ........... ...........
50220.............. Remove kidney, open....... .................. C................. ........... ........... ........... ........... ...........
50225.............. Removal kidney open, .................. C................. ........... ........... ........... ........... ...........
complex.
50230.............. Removal kidney open, .................. C................. ........... ........... ........... ........... ...........
radical.
50234.............. Removal of kidney & ureter .................. C................. ........... ........... ........... ........... ...........
50236.............. Removal of kidney & ureter .................. C................. ........... ........... ........... ........... ...........
50240.............. Partial removal of kidney. .................. C................. ........... ........... ........... ........... ...........
50250.............. Cryoablate renal mass open .................. C................. ........... ........... ........... ........... ...........
50280.............. Removal of kidney lesion.. .................. C................. ........... ........... ........... ........... ...........
50290.............. Removal of kidney lesion.. .................. C................. ........... ........... ........... ........... ...........
50300.............. Remove cadaver donor .................. C................. ........... ........... ........... ........... ...........
kidney.
50320.............. Remove kidney, living .................. C................. ........... ........... ........... ........... ...........
donor.
50323.............. Prep cadaver renal .................. C................. ........... ........... ........... ........... ...........
allograft.
50325.............. Prep donor renal graft.... .................. C................. ........... ........... ........... ........... ...........
50327.............. Prep renal graft/venous... .................. C................. ........... ........... ........... ........... ...........
50328.............. Prep renal graft/arterial. .................. C................. ........... ........... ........... ........... ...........
50329.............. Prep renal graft/ureteral. .................. C................. ........... ........... ........... ........... ...........
50340.............. Removal of kidney......... .................. C................. ........... ........... ........... ........... ...........
50360.............. Transplantation of kidney. .................. C................. ........... ........... ........... ........... ...........
50365.............. Transplantation of kidney. .................. C................. ........... ........... ........... ........... ...........
50370.............. Remove transplanted kidney .................. C................. ........... ........... ........... ........... ...........
50380.............. Reimplantation of kidney.. .................. C................. ........... ........... ........... ........... ...........
50382.............. Change ureter stent, CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
percut.
50384.............. Remove ureter stent, .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
percut.
50385.............. Change stent via NI................ T................. 0161 17.9420 $1,142.80 $241.15 $228.56
transureth.
50386.............. Remove stent via NI................ T................. 0160 5.9735 $380.48 ........... $76.10
transureth.
50387.............. Change ext/int ureter CH................ T................. 0427 15.3545 $977.99 ........... $195.60
stent.
50389.............. Remove renal tube w/fluoro CH................ T................. 0160 5.9735 $380.48 ........... $76.10
50390.............. Drainage of kidney lesion. .................. T................. 0685 9.3354 $594.61 ........... $118.92
50391.............. Instll rx agnt into rnal .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
tub.
50392.............. Insert kidney drain....... .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
50393.............. Insert ureteral tube...... CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
50394.............. Injection for kidney x-ray .................. N................. ........... ........... ........... ........... ...........
50395.............. Create passage to kidney.. .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
50396.............. Measure kidney pressure... .................. T................. 0164 2.0077 $127.88 ........... $25.58
50398.............. Change kidney tube........ CH................ T................. 0427 15.3545 $977.99 ........... $195.60
50400.............. Revision of kidney/ureter. .................. C................. ........... ........... ........... ........... ...........
50405.............. Revision of kidney/ureter. .................. C................. ........... ........... ........... ........... ...........
50500.............. Repair of kidney wound.... .................. C................. ........... ........... ........... ........... ...........
5050F.............. Plan 2 main Dr. by 1 month NI................ M................. ........... ........... ........... ........... ...........
50520.............. Close kidney-skin fistula. .................. C................. ........... ........... ........... ........... ...........
50525.............. Repair renal-abdomen .................. C................. ........... ........... ........... ........... ...........
fistula.
50526.............. Repair renal-abdomen .................. C................. ........... ........... ........... ........... ...........
fistula.
50540.............. Revision of horseshoe .................. C................. ........... ........... ........... ........... ...........
kidney.
50541.............. Laparo ablate renal cyst.. .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
50542.............. Laparo ablate renal mass.. .................. T................. 0132 69.6652 $4,437.26 $1,239.22 $887.45
50543.............. Laparo partial nephrectomy .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
50544.............. Laparoscopy, pyeloplasty.. .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
50545.............. Laparo radical nephrectomy .................. C................. ........... ........... ........... ........... ...........
50546.............. Laparoscopic nephrectomy.. .................. C................. ........... ........... ........... ........... ...........
50547.............. Laparo removal donor .................. C................. ........... ........... ........... ........... ...........
kidney.
50548.............. Laparo remove w/ureter.... .................. C................. ........... ........... ........... ........... ...........
50549.............. Laparoscope proc, renal... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
50551.............. Kidney endoscopy.......... .................. T................. 0160 5.9735 $380.48 ........... $76.10
50553.............. Kidney endoscopy.......... CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
50555.............. Kidney endoscopy & biopsy. .................. T................. 0160 5.9735 $380.48 ........... $76.10
50557.............. Kidney endoscopy & .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
treatment.
50561.............. Kidney endoscopy & CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
treatment.
50562.............. Renal scope w/tumor resect .................. T................. 0160 5.9735 $380.48 ........... $76.10
50570.............. Kidney endoscopy.......... .................. T................. 0160 5.9735 $380.48 ........... $76.10
50572.............. Kidney endoscopy.......... .................. T................. 0160 5.9735 $380.48 ........... $76.10
50574.............. Kidney endoscopy & biopsy. .................. T................. 0160 5.9735 $380.48 ........... $76.10
50575.............. Kidney endoscopy.......... .................. T................. 0163 36.0774 $2,297.91 ........... $459.58
50576.............. Kidney endoscopy & .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
treatment.
50580.............. Kidney endoscopy & CH................ T................. 0161 17.9420 $1,142.80 $241.15 $228.56
treatment.
50590.............. Fragmenting of kidney .................. T................. 0169 41.5299 $2,645.21 $997.74 $529.04
stone.
50592.............. Perc rf ablate renal tumor .................. T................. 0423 42.9980 $2,738.71 ........... $547.74
50593.............. Perc cryo ablate renal tum NI................ T................. 0423 42.9980 $2,738.71 ........... $547.74
50600.............. Exploration of ureter..... .................. C................. ........... ........... ........... ........... ...........
50605.............. Insert ureteral support... .................. C................. ........... ........... ........... ........... ...........
50610.............. Removal of ureter stone... .................. C................. ........... ........... ........... ........... ...........
[[Page 67051]]
50620.............. Removal of ureter stone... .................. C................. ........... ........... ........... ........... ...........
50630.............. Removal of ureter stone... .................. C................. ........... ........... ........... ........... ...........
50650.............. Removal of ureter......... .................. C................. ........... ........... ........... ........... ...........
50660.............. Removal of ureter......... .................. C................. ........... ........... ........... ........... ...........
50684.............. Injection for ureter x-ray .................. N................. ........... ........... ........... ........... ...........
50686.............. Measure ureter pressure... .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
50688.............. Change of ureter tube/ CH................ T................. 0427 15.3545 $977.99 ........... $195.60
stent.
50690.............. Injection for ureter x-ray .................. N................. ........... ........... ........... ........... ...........
50700.............. Revision of ureter........ .................. C................. ........... ........... ........... ........... ...........
50715.............. Release of ureter......... .................. C................. ........... ........... ........... ........... ...........
50722.............. Release of ureter......... .................. C................. ........... ........... ........... ........... ...........
50725.............. Release/revise ureter..... .................. C................. ........... ........... ........... ........... ...........
50727.............. Revise ureter............. .................. C................. ........... ........... ........... ........... ...........
50728.............. Revise ureter............. .................. C................. ........... ........... ........... ........... ...........
50740.............. Fusion of ureter & kidney. .................. C................. ........... ........... ........... ........... ...........
50750.............. Fusion of ureter & kidney. .................. C................. ........... ........... ........... ........... ...........
50760.............. Fusion of ureters......... .................. C................. ........... ........... ........... ........... ...........
50770.............. Splicing of ureters....... .................. C................. ........... ........... ........... ........... ...........
50780.............. Reimplant ureter in .................. C................. ........... ........... ........... ........... ...........
bladder.
50782.............. Reimplant ureter in .................. C................. ........... ........... ........... ........... ...........
bladder.
50783.............. Reimplant ureter in .................. C................. ........... ........... ........... ........... ...........
bladder.
50785.............. Reimplant ureter in .................. C................. ........... ........... ........... ........... ...........
bladder.
50800.............. Implant ureter in bowel... .................. C................. ........... ........... ........... ........... ...........
50810.............. Fusion of ureter & bowel.. .................. C................. ........... ........... ........... ........... ...........
50815.............. Urine shunt to intestine.. .................. C................. ........... ........... ........... ........... ...........
50820.............. Construct bowel bladder... .................. C................. ........... ........... ........... ........... ...........
50825.............. Construct bowel bladder... .................. C................. ........... ........... ........... ........... ...........
50830.............. Revise urine flow......... .................. C................. ........... ........... ........... ........... ...........
50840.............. Replace ureter by bowel... .................. C................. ........... ........... ........... ........... ...........
50845.............. Appendico-vesicostomy..... .................. C................. ........... ........... ........... ........... ...........
50860.............. Transplant ureter to skin. .................. C................. ........... ........... ........... ........... ...........
50900.............. Repair of ureter.......... .................. C................. ........... ........... ........... ........... ...........
50920.............. Closure ureter/skin .................. C................. ........... ........... ........... ........... ...........
fistula.
50930.............. Closure ureter/bowel .................. C................. ........... ........... ........... ........... ...........
fistula.
50940.............. Release of ureter......... .................. C................. ........... ........... ........... ........... ...........
50945.............. Laparoscopy .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
ureterolithotomy.
50947.............. Laparo new ureter/bladder. .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
50948.............. Laparo new ureter/bladder. .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
50949.............. Laparoscope proc, ureter.. .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
50951.............. Endoscopy of ureter....... .................. T................. 0160 5.9735 $380.48 ........... $76.10
50953.............. Endoscopy of ureter....... .................. T................. 0160 5.9735 $380.48 ........... $76.10
50955.............. Ureter endoscopy & biopsy. CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
50957.............. Ureter endoscopy & CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
treatment.
50961.............. Ureter endoscopy & CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
treatment.
50970.............. Ureter endoscopy.......... .................. T................. 0160 5.9735 $380.48 ........... $76.10
50972.............. Ureter endoscopy & .................. T................. 0160 5.9735 $380.48 ........... $76.10
catheter.
50974.............. Ureter endoscopy & biopsy. .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
50976.............. Ureter endoscopy & .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
treatment.
50980.............. Ureter endoscopy & CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
treatment.
51000.............. Drainage of bladder....... CH................ D................. ........... ........... ........... ........... ...........
51005.............. Drainage of bladder....... CH................ D................. ........... ........... ........... ........... ...........
51010.............. Drainage of bladder....... CH................ D................. ........... ........... ........... ........... ...........
51020.............. Incise & treat bladder.... .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
51030.............. Incise & treat bladder.... .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
51040.............. Incise & drain bladder.... .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
51045.............. Incise bladder/drain .................. T................. 0160 5.9735 $380.48 ........... $76.10
ureter.
51050.............. Removal of bladder stone.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
51060.............. Removal of ureter stone... .................. C................. ........... ........... ........... ........... ...........
51065.............. Remove ureter calculus.... .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
51080.............. Drainage of bladder .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
abscess.
51100.............. Drain bladder by needle... NI................ T................. 0164 2.0077 $127.88 ........... $25.58
51101.............. Drain bladder by trocar/ NI................ T................. 0126 1.0356 $65.96 $16.21 $13.19
cath.
51102.............. Drain bl w/cath insertion. NI................ T................. 0165 19.3414 $1,231.93 ........... $246.39
51500.............. Removal of bladder cyst... .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
51520.............. Removal of bladder lesion. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
51525.............. Removal of bladder lesion. .................. C................. ........... ........... ........... ........... ...........
51530.............. Removal of bladder lesion. .................. C................. ........... ........... ........... ........... ...........
51535.............. Repair of ureter lesion... CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
51550.............. Partial removal of bladder .................. C................. ........... ........... ........... ........... ...........
51555.............. Partial removal of bladder .................. C................. ........... ........... ........... ........... ...........
51565.............. Revise bladder & ureter(s) .................. C................. ........... ........... ........... ........... ...........
51570.............. Removal of bladder........ .................. C................. ........... ........... ........... ........... ...........
51575.............. Removal of bladder & nodes .................. C................. ........... ........... ........... ........... ...........
51580.............. Remove bladder/revise .................. C................. ........... ........... ........... ........... ...........
tract.
51585.............. Removal of bladder & nodes .................. C................. ........... ........... ........... ........... ...........
51590.............. Remove bladder/revise .................. C................. ........... ........... ........... ........... ...........
tract.
51595.............. Remove bladder/revise .................. C................. ........... ........... ........... ........... ...........
tract.
51596.............. Remove bladder/create .................. C................. ........... ........... ........... ........... ...........
pouch.
51597.............. Removal of pelvic .................. C................. ........... ........... ........... ........... ...........
structures.
51600.............. Injection for bladder x- .................. N................. ........... ........... ........... ........... ...........
ray.
[[Page 67052]]
51605.............. Preparation for bladder .................. N................. ........... ........... ........... ........... ...........
xray.
51610.............. Injection for bladder x- .................. N................. ........... ........... ........... ........... ...........
ray.
51700.............. Irrigation of bladder..... .................. T................. 0164 2.0077 $127.88 ........... $25.58
51701.............. Insert bladder catheter... .................. X................. 0340 0.6310 $40.19 ........... $8.04
51702.............. Insert temp bladder cath.. .................. X................. 0340 0.6310 $40.19 ........... $8.04
51703.............. Insert bladder cath, .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
complex.
51705.............. Change of bladder tube.... CH................ T................. 0164 2.0077 $127.88 ........... $25.58
51710.............. Change of bladder tube.... CH................ T................. 0427 15.3545 $977.99 ........... $195.60
51715.............. Endoscopic injection/ .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
implant.
51720.............. Treatment of bladder .................. T................. 0164 2.0077 $127.88 ........... $25.58
lesion.
51725.............. Simple cystometrogram..... CH................ T................. 0156 3.0469 $194.07 ........... $38.81
51726.............. Complex cystometrogram.... .................. T................. 0156 3.0469 $194.07 ........... $38.81
51736.............. Urine flow measurement.... .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
51741.............. Electro-uroflowmetry, .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
first.
51772.............. Urethra pressure profile.. .................. T................. 0164 2.0077 $127.88 ........... $25.58
51784.............. Anal/urinary muscle study. .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
51785.............. Anal/urinary muscle study. CH................ T................. 0164 2.0077 $127.88 ........... $25.58
51792.............. Urinary reflex study...... .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
51795.............. Urine voiding pressure .................. T................. 0164 2.0077 $127.88 ........... $25.58
study.
51797.............. Intraabdominal pressure .................. T................. 0164 2.0077 $127.88 ........... $25.58
test.
51798.............. Us urine capacity measure. .................. X................. 0340 0.6310 $40.19 ........... $8.04
51800.............. Revision of bladder/ .................. C................. ........... ........... ........... ........... ...........
urethra.
51820.............. Revision of urinary tract. .................. C................. ........... ........... ........... ........... ...........
51840.............. Attach bladder/urethra.... .................. C................. ........... ........... ........... ........... ...........
51841.............. Attach bladder/urethra.... .................. C................. ........... ........... ........... ........... ...........
51845.............. Repair bladder neck....... .................. C................. ........... ........... ........... ........... ...........
51860.............. Repair of bladder wound... .................. C................. ........... ........... ........... ........... ...........
51865.............. Repair of bladder wound... .................. C................. ........... ........... ........... ........... ...........
51880.............. Repair of bladder opening. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
51900.............. Repair bladder/vagina .................. C................. ........... ........... ........... ........... ...........
lesion.
51920.............. Close bladder-uterus .................. C................. ........... ........... ........... ........... ...........
fistula.
51925.............. Hysterectomy/bladder .................. C................. ........... ........... ........... ........... ...........
repair.
51940.............. Correction of bladder .................. C................. ........... ........... ........... ........... ...........
defect.
51960.............. Revision of bladder & .................. C................. ........... ........... ........... ........... ...........
bowel.
51980.............. Construct bladder opening. .................. C................. ........... ........... ........... ........... ...........
51990.............. Laparo urethral suspension .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
51992.............. Laparo sling operation.... .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
51999.............. Laparoscope proc, bla..... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
52000.............. Cystoscopy................ .................. T................. 0160 5.9735 $380.48 ........... $76.10
52001.............. Cystoscopy, removal of CH................ T................. 0161 17.9420 $1,142.80 $241.15 $228.56
clots.
52005.............. Cystoscopy & ureter .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
catheter.
52007.............. Cystoscopy and biopsy..... CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
52010.............. Cystoscopy & duct catheter .................. T................. 0160 5.9735 $380.48 ........... $76.10
52204.............. Cystoscopy w/biopsy(s).... .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
52214.............. Cystoscopy and treatment.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52224.............. Cystoscopy and treatment.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52234.............. Cystoscopy and treatment.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52235.............. Cystoscopy and treatment.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52240.............. Cystoscopy and treatment.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52250.............. Cystoscopy and radiotracer .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52260.............. Cystoscopy and treatment.. .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
52265.............. Cystoscopy and treatment.. .................. T................. 0160 5.9735 $380.48 ........... $76.10
52270.............. Cystoscopy & revise .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
urethra.
52275.............. Cystoscopy & revise CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
urethra.
52276.............. Cystoscopy and treatment.. CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
52277.............. Cystoscopy and treatment.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52281.............. Cystoscopy and treatment.. .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
52282.............. Cystoscopy, implant stent. .................. T................. 0163 36.0774 $2,297.91 ........... $459.58
52283.............. Cystoscopy and treatment.. CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
52285.............. Cystoscopy and treatment.. .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
52290.............. Cystoscopy and treatment.. .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
52300.............. Cystoscopy and treatment.. CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
52301.............. Cystoscopy and treatment.. CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
52305.............. Cystoscopy and treatment.. CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
52310.............. Cystoscopy and treatment.. CH................ T................. 0161 17.9420 $1,142.80 $241.15 $228.56
52315.............. Cystoscopy and treatment.. CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
52317.............. Remove bladder stone...... .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52318.............. Remove bladder stone...... .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52320.............. Cystoscopy and treatment.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52325.............. Cystoscopy, stone removal. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52327.............. Cystoscopy, inject .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
material.
52330.............. Cystoscopy and treatment.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52332.............. Cystoscopy and treatment.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52334.............. Create passage to kidney.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52341.............. Cysto w/ureter stricture .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
tx.
52342.............. Cysto w/up stricture tx... .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52343.............. Cysto w/renal stricture tx .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52344.............. Cysto/uretero, stricture .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
tx.
52345.............. Cysto/uretero w/up .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
stricture.
52346.............. Cystouretero w/renal .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
strict.
[[Page 67053]]
52351.............. Cystouretero & or CH................ T................. 0162 24.7749 $1,578.01 ........... $315.60
pyeloscope.
52352.............. Cystouretero w/stone .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
remove.
52353.............. Cystouretero w/lithotripsy .................. T................. 0163 36.0774 $2,297.91 ........... $459.58
52354.............. Cystouretero w/biopsy..... .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52355.............. Cystouretero w/excise .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
tumor.
52400.............. Cystouretero w/congen repr .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52402.............. Cystourethro cut ejacul .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
duct.
52450.............. Incision of prostate...... .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52500.............. Revision of bladder neck.. .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52510.............. Dilation prostatic urethra CH................ D................. ........... ........... ........... ........... ...........
52601.............. Prostatectomy (TURP)...... .................. T................. 0163 36.0774 $2,297.91 ........... $459.58
52606.............. Control postop bleeding... .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
52612.............. Prostatectomy, first stage .................. T................. 0163 36.0774 $2,297.91 ........... $459.58
52614.............. Prostatectomy, second .................. T................. 0163 36.0774 $2,297.91 ........... $459.58
stage.
52620.............. Remove residual prostate.. .................. T................. 0163 36.0774 $2,297.91 ........... $459.58
52630.............. Remove prostate regrowth.. .................. T................. 0163 36.0774 $2,297.91 ........... $459.58
52640.............. Relieve bladder .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
contracture.
52647.............. Laser surgery of prostate. .................. T................. 0429 45.2042 $2,879.24 ........... $575.85
52648.............. Laser surgery of prostate. .................. T................. 0429 45.2042 $2,879.24 ........... $575.85
52649.............. Prostate laser enucleation NI................ T................. 0429 45.2042 $2,879.24 ........... $575.85
52700.............. Drainage of prostate .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
abscess.
53000.............. Incision of urethra....... .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53010.............. Incision of urethra....... .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53020.............. Incision of urethra....... .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53025.............. Incision of urethra....... .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53040.............. Drainage of urethra .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
abscess.
53060.............. Drainage of urethra .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
abscess.
53080.............. Drainage of urinary .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
leakage.
53085.............. Drainage of urinary .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
leakage.
53200.............. Biopsy of urethra......... .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53210.............. Removal of urethra........ .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53215.............. Removal of urethra........ .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53220.............. Treatment of urethra .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
lesion.
53230.............. Removal of urethra lesion. .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53235.............. Removal of urethra lesion. .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53240.............. Surgery for urethra pouch. .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53250.............. Removal of urethra gland.. .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53260.............. Treatment of urethra .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
lesion.
53265.............. Treatment of urethra .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
lesion.
53270.............. Removal of urethra gland.. .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53275.............. Repair of urethra defect.. .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53400.............. Revise urethra, stage 1... .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53405.............. Revise urethra, stage 2... .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53410.............. Reconstruction of urethra. .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53415.............. Reconstruction of urethra. .................. C................. ........... ........... ........... ........... ...........
53420.............. Reconstruct urethra, stage .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
1.
53425.............. Reconstruct urethra, stage .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
2.
53430.............. Reconstruction of urethra. .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53431.............. Reconstruct urethra/ .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
bladder.
53440.............. Male sling procedure...... .................. S................. 0385 83.6366 $5,327.15 ........... $1,065.43
53442.............. Remove/revise male sling.. .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53444.............. Insert tandem cuff........ .................. S................. 0385 83.6366 $5,327.15 ........... $1,065.43
53445.............. Insert uro/ves nck .................. S................. 0386 144.1246 $9,179.87 ........... $1,835.97
sphincter.
53446.............. Remove uro sphincter...... .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53447.............. Remove/replace ur .................. S................. 0386 144.1246 $9,179.87 ........... $1,835.97
sphincter.
53448.............. Remov/replc ur sphinctr .................. C................. ........... ........... ........... ........... ...........
comp.
53449.............. Repair uro sphincter...... .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53450.............. Revision of urethra....... .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53460.............. Revision of urethra....... .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53500.............. Urethrlys, transvag w/ .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
scope.
53502.............. Repair of urethra injury.. .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53505.............. Repair of urethra injury.. .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53510.............. Repair of urethra injury.. .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53515.............. Repair of urethra injury.. .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53520.............. Repair of urethra defect.. .................. T................. 0168 29.7864 $1,897.21 $388.16 $379.44
53600.............. Dilate urethra stricture.. .................. T................. 0156 3.0469 $194.07 ........... $38.81
53601.............. Dilate urethra stricture.. .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
53605.............. Dilate urethra stricture.. .................. T................. 0161 17.9420 $1,142.80 $241.15 $228.56
53620.............. Dilate urethra stricture.. .................. T................. 0165 19.3414 $1,231.93 ........... $246.39
53621.............. Dilate urethra stricture.. .................. T................. 0164 2.0077 $127.88 ........... $25.58
53660.............. Dilation of urethra....... .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
53661.............. Dilation of urethra....... .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
53665.............. Dilation of urethra....... .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
53850.............. Prostatic microwave CH................ T................. 0429 45.2042 $2,879.24 ........... $575.85
thermotx.
53852.............. Prostatic rf thermotx..... CH................ T................. 0429 45.2042 $2,879.24 ........... $575.85
53853.............. Prostatic water thermother .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
53899.............. Urology surgery procedure. .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
54000.............. Slitting of prepuce....... .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
54001.............. Slitting of prepuce....... .................. T................. 0166 19.1505 $1,219.77 ........... $243.95
54015.............. Drain penis lesion........ .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
[[Page 67054]]
54050.............. Destruction, penis CH................ T................. 0015 1.4595 $92.96 ........... $18.59
lesion(s).
54055.............. Destruction, penis .................. T................. 0017 19.9041 $1,267.77 ........... $253.55
lesion(s).
54056.............. Cryosurgery, penis CH................ T................. 0013 0.7930 $50.51 ........... $10.10
lesion(s).
54057.............. Laser surg, penis .................. T................. 0017 19.9041 $1,267.77 ........... $253.55
lesion(s).
54060.............. Excision of penis .................. T................. 0017 19.9041 $1,267.77 ........... $253.55
lesion(s).
54065.............. Destruction, penis CH................ T................. 0017 19.9041 $1,267.77 ........... $253.55
lesion(s).
54100.............. Biopsy of penis........... .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
54105.............. Biopsy of penis........... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
54110.............. Treatment of penis lesion. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54111.............. Treat penis lesion, graft. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54112.............. Treat penis lesion, graft. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54115.............. Treatment of penis lesion. .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
54120.............. Partial removal of penis.. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54125.............. Removal of penis.......... .................. C................. ........... ........... ........... ........... ...........
54130.............. Remove penis & nodes...... .................. C................. ........... ........... ........... ........... ...........
54135.............. Remove penis & nodes...... .................. C................. ........... ........... ........... ........... ...........
54150.............. Circumcision w/regionl CH................ T................. 0183 22.3251 $1,421.97 ........... $284.39
block.
54160.............. Circumcision, neonate..... CH................ T................. 0183 22.3251 $1,421.97 ........... $284.39
54161.............. Circum 28 days or older... CH................ T................. 0183 22.3251 $1,421.97 ........... $284.39
54162.............. Lysis penil circumic CH................ T................. 0183 22.3251 $1,421.97 ........... $284.39
lesion.
54163.............. Repair of circumcision.... CH................ T................. 0183 22.3251 $1,421.97 ........... $284.39
54164.............. Frenulotomy of penis...... CH................ T................. 0183 22.3251 $1,421.97 ........... $284.39
54200.............. Treatment of penis lesion. .................. T................. 0164 2.0077 $127.88 ........... $25.58
54205.............. Treatment of penis lesion. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54220.............. Treatment of penis lesion. .................. T................. 0164 2.0077 $127.88 ........... $25.58
54230.............. Prepare penis study....... .................. N................. ........... ........... ........... ........... ...........
54231.............. Dynamic cavernosometry.... .................. T................. 0165 19.3414 $1,231.93 ........... $246.39
54235.............. Penile injection.......... .................. T................. 0164 2.0077 $127.88 ........... $25.58
54240.............. Penis study............... .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
54250.............. Penis study............... .................. T................. 0164 2.0077 $127.88 ........... $25.58
54300.............. Revision of penis......... .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54304.............. Revision of penis......... .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54308.............. Reconstruction of urethra. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54312.............. Reconstruction of urethra. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54316.............. Reconstruction of urethra. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54318.............. Reconstruction of urethra. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54322.............. Reconstruction of urethra. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54324.............. Reconstruction of urethra. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54326.............. Reconstruction of urethra. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54328.............. Revise penis/urethra...... .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54332.............. Revise penis/urethra...... .................. C................. ........... ........... ........... ........... ...........
54336.............. Revise penis/urethra...... .................. C................. ........... ........... ........... ........... ...........
54340.............. Secondary urethral surgery .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54344.............. Secondary urethral surgery .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54348.............. Secondary urethral surgery .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54352.............. Reconstruct urethra/penis. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54360.............. Penis plastic surgery..... .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54380.............. Repair penis.............. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54385.............. Repair penis.............. .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54390.............. Repair penis and bladder.. .................. C................. ........... ........... ........... ........... ...........
54400.............. Insert semi-rigid .................. S................. 0385 83.6366 $5,327.15 ........... $1,065.43
prosthesis.
54401.............. Insert self-contd .................. S................. 0386 144.1246 $9,179.87 ........... $1,835.97
prosthesis.
54405.............. Insert multi-comp penis .................. S................. 0386 144.1246 $9,179.87 ........... $1,835.97
pros.
54406.............. Remove muti-comp penis .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
pros.
54408.............. Repair multi-comp penis .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
pros.
54410.............. Remove/replace penis .................. S................. 0386 144.1246 $9,179.87 ........... $1,835.97
prosth.
54411.............. Remov/replc penis pros, .................. C................. ........... ........... ........... ........... ...........
comp.
54415.............. Remove self-contd penis .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
pros.
54416.............. Remv/repl penis contain .................. S................. 0386 144.1246 $9,179.87 ........... $1,835.97
pros.
54417.............. Remv/replc penis pros, .................. C................. ........... ........... ........... ........... ...........
compl.
54420.............. Revision of penis......... .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54430.............. Revision of penis......... .................. C................. ........... ........... ........... ........... ...........
54435.............. Revision of penis......... .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54440.............. Repair of penis........... .................. T................. 0181 33.9306 $2,161.18 $621.82 $432.24
54450.............. Preputial stretching...... .................. T................. 0156 3.0469 $194.07 ........... $38.81
54500.............. Biopsy of testis.......... .................. T................. 0037 13.5764 $864.74 $228.76 $172.95
54505.............. Biopsy of testis.......... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54512.............. Excise lesion testis...... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54520.............. Removal of testis......... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54522.............. Orchiectomy, partial...... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54530.............. Removal of testis......... .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
54535.............. Extensive testis surgery.. .................. C................. ........... ........... ........... ........... ...........
54550.............. Exploration for testis.... .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
54560.............. Exploration for testis.... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54600.............. Reduce testis torsion..... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54620.............. Suspension of testis...... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54640.............. Suspension of testis...... .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
54650.............. Orchiopexy (Fowler- .................. C................. ........... ........... ........... ........... ...........
Stephens).
54660.............. Revision of testis........ .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54670.............. Repair testis injury...... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
[[Page 67055]]
54680.............. Relocation of testis(es).. .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54690.............. Laparoscopy, orchiectomy.. .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
54692.............. Laparoscopy, orchiopexy... .................. T................. 0132 69.6652 $4,437.26 $1,239.22 $887.45
54699.............. Laparoscope proc, testis.. .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
54700.............. Drainage of scrotum....... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54800.............. Biopsy of epididymis...... .................. T................. 0004 4.3270 $275.60 ........... $55.12
54830.............. Remove epididymis lesion.. .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54840.............. Remove epididymis lesion.. .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54860.............. Removal of epididymis..... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54861.............. Removal of epididymis..... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54865.............. Explore epididymis........ .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54900.............. Fusion of spermatic ducts. .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
54901.............. Fusion of spermatic ducts. .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55000.............. Drainage of hydrocele..... .................. T................. 0004 4.3270 $275.60 ........... $55.12
55040.............. Removal of hydrocele...... .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
55041.............. Removal of hydroceles..... .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
55060.............. Repair of hydrocele....... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55100.............. Drainage of scrotum .................. T................. 0007 11.5594 $736.26 ........... $147.25
abscess.
55110.............. Explore scrotum........... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55120.............. Removal of scrotum lesion. .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55150.............. Removal of scrotum........ .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55175.............. Revision of scrotum....... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55180.............. Revision of scrotum....... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55200.............. Incision of sperm duct.... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55250.............. Removal of sperm duct(s).. .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55300.............. Prepare, sperm duct x-ray. .................. N................. ........... ........... ........... ........... ...........
55400.............. Repair of sperm duct...... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55450.............. Ligation of sperm duct.... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55500.............. Removal of hydrocele...... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55520.............. Removal of sperm cord .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
lesion.
55530.............. Revise spermatic cord .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
veins.
55535.............. Revise spermatic cord .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
veins.
55540.............. Revise hernia & sperm .................. T................. 0154 30.6788 $1,954.06 $464.85 $390.81
veins.
55550.............. Laparo ligate spermatic .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
vein.
55559.............. Laparo proc, spermatic .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
cord.
55600.............. Incise sperm duct pouch... .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55605.............. Incise sperm duct pouch... .................. C................. ........... ........... ........... ........... ...........
55650.............. Remove sperm duct pouch... .................. C................. ........... ........... ........... ........... ...........
55680.............. Remove sperm pouch lesion. .................. T................. 0183 22.3251 $1,421.97 ........... $284.39
55700.............. Biopsy of prostate........ .................. T................. 0184 11.0338 $702.79 ........... $140.56
55705.............. Biopsy of prostate........ .................. T................. 0184 11.0338 $702.79 ........... $140.56
55720.............. Drainage of prostate .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
abscess.
55725.............. Drainage of prostate .................. T................. 0162 24.7749 $1,578.01 ........... $315.60
abscess.
55801.............. Removal of prostate....... .................. C................. ........... ........... ........... ........... ...........
55810.............. Extensive prostate surgery .................. C................. ........... ........... ........... ........... ...........
55812.............. Extensive prostate surgery .................. C................. ........... ........... ........... ........... ...........
55815.............. Extensive prostate surgery .................. C................. ........... ........... ........... ........... ...........
55821.............. Removal of prostate....... .................. C................. ........... ........... ........... ........... ...........
55831.............. Removal of prostate....... .................. C................. ........... ........... ........... ........... ...........
55840.............. Extensive prostate surgery .................. C................. ........... ........... ........... ........... ...........
55842.............. Extensive prostate surgery .................. C................. ........... ........... ........... ........... ...........
55845.............. Extensive prostate surgery .................. C................. ........... ........... ........... ........... ...........
55860.............. Surgical exposure, .................. T................. 0165 19.3414 $1,231.93 ........... $246.39
prostate.
55862.............. Extensive prostate surgery .................. C................. ........... ........... ........... ........... ...........
55865.............. Extensive prostate surgery .................. C................. ........... ........... ........... ........... ...........
55866.............. Laparo radical .................. C................. ........... ........... ........... ........... ...........
prostatectomy.
55870.............. Electroejaculation........ CH................ T................. 0189 2.7584 $175.69 ........... $35.14
55873.............. Cryoablate prostate....... .................. T................. 0674 122.7133 $7,816.10 ........... $1,563.22
55875.............. Transperi needle place, CH................ Q................. 0163 36.0774 $2,297.91 ........... $459.58
pros.
55876.............. Place rt device/marker, .................. T................. 0156 3.0469 $194.07 ........... $38.81
pros.
55899.............. Genital surgery procedure. .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
55920.............. Place needles pelvic for NI................ T................. 0153 25.6947 $1,636.60 $397.95 $327.32
rt.
55970.............. Sex transformation, M to F .................. E................. ........... ........... ........... ........... ...........
55980.............. Sex transformation, F to M .................. E................. ........... ........... ........... ........... ...........
56405.............. I & D of vulva/perineum... .................. T................. 0189 2.7584 $175.69 ........... $35.14
56420.............. Drainage of gland abscess. .................. T................. 0188 1.3520 $86.11 ........... $17.22
56440.............. Surgery for vulva lesion.. CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
56441.............. Lysis of labial lesion(s). .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
56442.............. Hymenotomy................ .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
56501.............. Destroy, vulva lesions, .................. T................. 0017 19.9041 $1,267.77 ........... $253.55
sim.
56515.............. Destroy vulva lesion/s CH................ T................. 0017 19.9041 $1,267.77 ........... $253.55
compl.
56605.............. Biopsy of vulva/perineum.. CH................ T................. 0189 2.7584 $175.69 ........... $35.14
56606.............. Biopsy of vulva/perineum.. CH................ T................. 0188 1.3520 $86.11 ........... $17.22
56620.............. Partial removal of vulva.. CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
56625.............. Complete removal of vulva. CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
56630.............. Extensive vulva surgery... .................. C................. ........... ........... ........... ........... ...........
56631.............. Extensive vulva surgery... .................. C................. ........... ........... ........... ........... ...........
56632.............. Extensive vulva surgery... .................. C................. ........... ........... ........... ........... ...........
56633.............. Extensive vulva surgery... .................. C................. ........... ........... ........... ........... ...........
56634.............. Extensive vulva surgery... .................. C................. ........... ........... ........... ........... ...........
[[Page 67056]]
56637.............. Extensive vulva surgery... .................. C................. ........... ........... ........... ........... ...........
56640.............. Extensive vulva surgery... .................. C................. ........... ........... ........... ........... ...........
56700.............. Partial removal of hymen.. CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
56740.............. Remove vagina gland lesion CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
56800.............. Repair of vagina.......... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
56805.............. Repair clitoris........... .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
56810.............. Repair of perineum........ CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
56820.............. Exam of vulva w/scope..... .................. T................. 0188 1.3520 $86.11 ........... $17.22
56821.............. Exam/biopsy of vulva w/ CH................ T................. 0188 1.3520 $86.11 ........... $17.22
scope.
57000.............. Exploration of vagina..... .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
57010.............. Drainage of pelvic abscess .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
57020.............. Drainage of pelvic fluid.. .................. T................. 0192 6.0783 $387.15 ........... $77.43
57022.............. I & d vaginal hematoma, pp .................. T................. 0007 11.5594 $736.26 ........... $147.25
57023.............. I & d vag hematoma, non-ob .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
57061.............. Destroy vag lesions, CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
simple.
57065.............. Destroy vag lesions, CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
complex.
57100.............. Biopsy of vagina.......... .................. T................. 0192 6.0783 $387.15 ........... $77.43
57105.............. Biopsy of vagina.......... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
57106.............. Remove vagina wall, CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
partial.
57107.............. Remove vagina tissue, part .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57109.............. Vaginectomy partial w/ .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
nodes.
57110.............. Remove vagina wall, .................. C................. ........... ........... ........... ........... ...........
complete.
57111.............. Remove vagina tissue, .................. C................. ........... ........... ........... ........... ...........
compl.
57112.............. Vaginectomy w/nodes, compl .................. C................. ........... ........... ........... ........... ...........
57120.............. Closure of vagina......... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57130.............. Remove vagina lesion...... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
57135.............. Remove vagina lesion...... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
57150.............. Treat vagina infection.... CH................ T................. 0188 1.3520 $86.11 ........... $17.22
57155.............. Insert uteri tandems/ .................. T................. 0192 6.0783 $387.15 ........... $77.43
ovoids.
57160.............. Insert pessary/other .................. T................. 0188 1.3520 $86.11 ........... $17.22
device.
57170.............. Fitting of diaphragm/cap.. .................. T................. 0191 0.1309 $8.34 $2.36 $1.67
57180.............. Treat vaginal bleeding.... CH................ T................. 0188 1.3520 $86.11 ........... $17.22
57200.............. Repair of vagina.......... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
57210.............. Repair vagina/perineum.... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
57220.............. Revision of urethra....... .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
57230.............. Repair of urethral lesion. .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57240.............. Repair bladder & vagina... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57250.............. Repair rectum & vagina.... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57260.............. Repair of vagina.......... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57265.............. Extensive repair of vagina .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
57267.............. Insert mesh/pelvic flr .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
addon.
57268.............. Repair of bowel bulge..... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57270.............. Repair of bowel pouch..... .................. C................. ........... ........... ........... ........... ...........
57280.............. Suspension of vagina...... .................. C................. ........... ........... ........... ........... ...........
57282.............. Colpopexy, extraperitoneal .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
57283.............. Colpopexy, intraperitoneal .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
57284.............. Repair paravag defect, .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
open.
57285.............. Repair paravag defect, vag NI................ T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57287.............. Revise/remove sling repair .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57288.............. Repair bladder defect..... .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
57289.............. Repair bladder & vagina... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57291.............. Construction of vagina.... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57292.............. Construct vagina with .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
graft.
57295.............. Revise vag graft via CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
vagina.
57296.............. Revise vag graft, open abd .................. C................. ........... ........... ........... ........... ...........
57300.............. Repair rectum-vagina .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
fistula.
57305.............. Repair rectum-vagina .................. C................. ........... ........... ........... ........... ...........
fistula.
57307.............. Fistula repair & colostomy .................. C................. ........... ........... ........... ........... ...........
57308.............. Fistula repair, .................. C................. ........... ........... ........... ........... ...........
transperine.
57310.............. Repair urethrovaginal .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
lesion.
57311.............. Repair urethrovaginal .................. C................. ........... ........... ........... ........... ...........
lesion.
57320.............. Repair bladder-vagina .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
lesion.
57330.............. Repair bladder-vagina .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
lesion.
57335.............. Repair vagina............. .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57400.............. Dilation of vagina........ CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
57410.............. Pelvic examination........ .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
57415.............. Remove vaginal foreign CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
body.
57420.............. Exam of vagina w/scope.... .................. T................. 0189 2.7584 $175.69 ........... $35.14
57421.............. Exam/biopsy of vag w/scope .................. T................. 0189 2.7584 $175.69 ........... $35.14
57423.............. Repair paravag defect, lap NI................ T................. 0202 42.7099 $2,720.36 $981.50 $544.07
57425.............. Laparoscopy, surg, .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
colpopexy.
57452.............. Exam of cervix w/scope.... CH................ T................. 0189 2.7584 $175.69 ........... $35.14
57454.............. Bx/curett of cervix w/ .................. T................. 0189 2.7584 $175.69 ........... $35.14
scope.
57455.............. Biopsy of cervix w/scope.. .................. T................. 0189 2.7584 $175.69 ........... $35.14
57456.............. Endocerv curettage w/scope .................. T................. 0189 2.7584 $175.69 ........... $35.14
57460.............. Bx of cervix w/scope, leep .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
57461.............. Conz of cervix w/scope, CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
leep.
57500.............. Biopsy of cervix.......... CH................ T................. 0192 6.0783 $387.15 ........... $77.43
57505.............. Endocervical curettage.... CH................ T................. 0192 6.0783 $387.15 ........... $77.43
57510.............. Cauterization of cervix... .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
[[Page 67057]]
57511.............. Cryocautery of cervix..... .................. T................. 0188 1.3520 $86.11 ........... $17.22
57513.............. Laser surgery of cervix... .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
57520.............. Conization of cervix...... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
57522.............. Conization of cervix...... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
57530.............. Removal of cervix......... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57531.............. Removal of cervix, radical .................. C................. ........... ........... ........... ........... ...........
57540.............. Removal of residual cervix .................. C................. ........... ........... ........... ........... ...........
57545.............. Remove cervix/repair .................. C................. ........... ........... ........... ........... ...........
pelvis.
57550.............. Removal of residual cervix .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
57555.............. Remove cervix/repair .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
vagina.
57556.............. Remove cervix, repair .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
bowel.
57558.............. D&c of cervical stump..... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
57700.............. Revision of cervix........ CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
57720.............. Revision of cervix........ CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
57800.............. Dilation of cervical canal .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
58100.............. Biopsy of uterus lining... .................. T................. 0188 1.3520 $86.11 ........... $17.22
58110.............. Bx done w/colposcopy add- CH................ N................. ........... ........... ........... ........... ...........
on.
58120.............. Dilation and curettage.... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
58140.............. Myomectomy abdom method... .................. C................. ........... ........... ........... ........... ...........
58145.............. Myomectomy vag method..... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
58146.............. Myomectomy abdom complex.. .................. C................. ........... ........... ........... ........... ...........
58150.............. Total hysterectomy........ .................. C................. ........... ........... ........... ........... ...........
58152.............. Total hysterectomy........ .................. C................. ........... ........... ........... ........... ...........
58180.............. Partial hysterectomy...... .................. C................. ........... ........... ........... ........... ...........
58200.............. Extensive hysterectomy.... .................. C................. ........... ........... ........... ........... ...........
58210.............. Extensive hysterectomy.... .................. C................. ........... ........... ........... ........... ...........
58240.............. Removal of pelvis contents .................. C................. ........... ........... ........... ........... ...........
58260.............. Vaginal hysterectomy...... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
58262.............. Vag hyst including t/o.... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
58263.............. Vag hyst w/t/o & vag .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
repair.
58267.............. Vag hyst w/urinary repair. .................. C................. ........... ........... ........... ........... ...........
58270.............. Vag hyst w/enterocele .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
repair.
58275.............. Hysterectomy/revise vagina .................. C................. ........... ........... ........... ........... ...........
58280.............. Hysterectomy/revise vagina .................. C................. ........... ........... ........... ........... ...........
58285.............. Extensive hysterectomy.... .................. C................. ........... ........... ........... ........... ...........
58290.............. Vag hyst complex.......... .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
58291.............. Vag hyst incl t/o, complex .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
58292.............. Vag hyst t/o & repair, .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
compl.
58293.............. Vag hyst w/uro repair, .................. C................. ........... ........... ........... ........... ...........
compl.
58294.............. Vag hyst w/enterocele, .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
compl.
58300.............. Insert intrauterine device .................. E................. ........... ........... ........... ........... ...........
58301.............. Remove intrauterine device .................. T................. 0188 1.3520 $86.11 ........... $17.22
58321.............. Artificial insemination... CH................ T................. 0189 2.7584 $175.69 ........... $35.14
58322.............. Artificial insemination... CH................ T................. 0189 2.7584 $175.69 ........... $35.14
58323.............. Sperm washing............. CH................ T................. 0189 2.7584 $175.69 ........... $35.14
58340.............. Catheter for hysterography .................. N................. ........... ........... ........... ........... ...........
58345.............. Reopen fallopian tube..... .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
58346.............. Insert heyman uteri .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
capsule.
58350.............. Reopen fallopian tube..... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
58353.............. Endometr ablate, thermal.. .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
58356.............. Endometrial cryoablation.. .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
58400.............. Suspension of uterus...... .................. C................. ........... ........... ........... ........... ...........
58410.............. Suspension of uterus...... .................. C................. ........... ........... ........... ........... ...........
58520.............. Repair of ruptured uterus. .................. C................. ........... ........... ........... ........... ...........
58540.............. Revision of uterus........ .................. C................. ........... ........... ........... ........... ...........
58541.............. Lsh, uterus 250 g or less. .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58542.............. Lsh w/t/o ut 250 g or less .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58543.............. Lsh uterus above 250 g.... .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58544.............. Lsh w/t/o uterus above 250 .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
g.
58545.............. Laparoscopic myomectomy... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
58546.............. Laparo-myomectomy, complex .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58548.............. Lap radical hyst.......... .................. C................. ........... ........... ........... ........... ...........
58550.............. Laparo-asst vag .................. T................. 0132 69.6652 $4,437.26 $1,239.22 $887.45
hysterectomy.
58552.............. Laparo-vag hyst incl t/o.. .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58553.............. Laparo-vag hyst, complex.. .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58554.............. Laparo-vag hyst w/t/o, .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
compl.
58555.............. Hysteroscopy, dx, sep proc .................. T................. 0190 21.6576 $1,379.46 $424.28 $275.89
58558.............. Hysteroscopy, biopsy...... .................. T................. 0190 21.6576 $1,379.46 $424.28 $275.89
58559.............. Hysteroscopy, lysis....... .................. T................. 0190 21.6576 $1,379.46 $424.28 $275.89
58560.............. Hysteroscopy, resect .................. T................. 0387 34.2048 $2,178.64 $655.55 $435.73
septum.
58561.............. Hysteroscopy, remove myoma .................. T................. 0387 34.2048 $2,178.64 $655.55 $435.73
58562.............. Hysteroscopy, remove fb... .................. T................. 0190 21.6576 $1,379.46 $424.28 $275.89
58563.............. Hysteroscopy, ablation.... .................. T................. 0387 34.2048 $2,178.64 $655.55 $435.73
58565.............. Hysteroscopy, .................. T................. 0202 42.7099 $2,720.36 $981.50 $544.07
sterilization.
58570.............. Tlh, uterus 250 g or less. NI................ T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58571.............. Tlh w/t/o 250 g or less... NI................ T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58572.............. Tlh, uterus over 250 g.... NI................ T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58573.............. Tlh w/t/o uterus over 250 NI................ T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
g.
58578.............. Laparo proc, uterus....... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
58579.............. Hysteroscope procedure.... .................. T................. 0190 21.6576 $1,379.46 $424.28 $275.89
[[Page 67058]]
58600.............. Division of fallopian tube .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
58605.............. Division of fallopian tube .................. C................. ........... ........... ........... ........... ...........
58611.............. Ligate oviduct(s) add-on.. .................. C................. ........... ........... ........... ........... ...........
58615.............. Occlude fallopian tube(s). CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
58660.............. Laparoscopy, lysis........ .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58661.............. Laparoscopy, remove adnexa .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58662.............. Laparoscopy, excise .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
lesions.
58670.............. Laparoscopy, tubal cautery .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58671.............. Laparoscopy, tubal block.. .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58672.............. Laparoscopy, fimbrioplasty .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58673.............. Laparoscopy, salpingostomy .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
58679.............. Laparo proc, oviduct-ovary .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
58700.............. Removal of fallopian tube. .................. C................. ........... ........... ........... ........... ...........
58720.............. Removal of ovary/tube(s).. .................. C................. ........... ........... ........... ........... ...........
58740.............. Revise fallopian tube(s).. .................. C................. ........... ........... ........... ........... ...........
58750.............. Repair oviduct............ .................. C................. ........... ........... ........... ........... ...........
58752.............. Revise ovarian tube(s).... .................. C................. ........... ........... ........... ........... ...........
58760.............. Remove tubal obstruction.. .................. C................. ........... ........... ........... ........... ...........
58770.............. Create new tubal opening.. .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
58800.............. Drainage of ovarian .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
cyst(s).
58805.............. Drainage of ovarian CH................ T................. 0195 32.4237 $2,065.20 $483.80 $413.04
cyst(s).
58820.............. Drain ovary abscess, open. .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
58822.............. Drain ovary abscess, .................. C................. ........... ........... ........... ........... ...........
percut.
58823.............. Drain pelvic abscess, .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
percut.
58825.............. Transposition, ovary(s)... .................. C................. ........... ........... ........... ........... ...........
58900.............. Biopsy of ovary(s)........ .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
58920.............. Partial removal of .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
ovary(s).
58925.............. Removal of ovarian cyst(s) .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
58940.............. Removal of ovary(s)....... .................. C................. ........... ........... ........... ........... ...........
58943.............. Removal of ovary(s)....... .................. C................. ........... ........... ........... ........... ...........
58950.............. Resect ovarian malignancy. .................. C................. ........... ........... ........... ........... ...........
58951.............. Resect ovarian malignancy. .................. C................. ........... ........... ........... ........... ...........
58952.............. Resect ovarian malignancy. .................. C................. ........... ........... ........... ........... ...........
58953.............. Tah, rad dissect for .................. C................. ........... ........... ........... ........... ...........
debulk.
58954.............. Tah rad debulk/lymph .................. C................. ........... ........... ........... ........... ...........
remove.
58956.............. Bso, omentectomy w/tah.... .................. C................. ........... ........... ........... ........... ...........
58957.............. Resect recurrent gyn mal.. .................. C................. ........... ........... ........... ........... ...........
58958.............. Resect recur gyn mal w/lym .................. C................. ........... ........... ........... ........... ...........
58960.............. Exploration of abdomen.... .................. C................. ........... ........... ........... ........... ...........
58970.............. Retrieval of oocyte....... CH................ T................. 0189 2.7584 $175.69 ........... $35.14
58974.............. Transfer of embryo........ CH................ T................. 0189 2.7584 $175.69 ........... $35.14
58976.............. Transfer of embryo........ CH................ T................. 0189 2.7584 $175.69 ........... $35.14
58999.............. Genital surgery procedure. .................. T................. 0191 0.1309 $8.34 $2.36 $1.67
59000.............. Amniocentesis, diagnostic. CH................ T................. 0189 2.7584 $175.69 ........... $35.14
59001.............. Amniocentesis, therapeutic .................. T................. 0192 6.0783 $387.15 ........... $77.43
59012.............. Fetal cord CH................ T................. 0189 2.7584 $175.69 ........... $35.14
puncture,prenatal.
59015.............. Chorion biopsy............ CH................ T................. 0189 2.7584 $175.69 ........... $35.14
59020.............. Fetal contract stress test CH................ T................. 0188 1.3520 $86.11 ........... $17.22
59025.............. Fetal non-stress test..... CH................ T................. 0188 1.3520 $86.11 ........... $17.22
59030.............. Fetal scalp blood sample.. CH................ T................. 0189 2.7584 $175.69 ........... $35.14
59050.............. Fetal monitor w/report.... .................. M................. ........... ........... ........... ........... ...........
59051.............. Fetal monitor/interpret .................. B................. ........... ........... ........... ........... ...........
only.
59070.............. Transabdom amnioinfus w/us CH................ T................. 0189 2.7584 $175.69 ........... $35.14
59072.............. Umbilical cord occlud w/us CH................ T................. 0189 2.7584 $175.69 ........... $35.14
59074.............. Fetal fluid drainage w/us. CH................ T................. 0189 2.7584 $175.69 ........... $35.14
59076.............. Fetal shunt placement, w/ CH................ T................. 0189 2.7584 $175.69 ........... $35.14
us.
59100.............. Remove uterus lesion...... .................. T................. 0195 32.4237 $2,065.20 $483.80 $413.04
59120.............. Treat ectopic pregnancy... .................. C................. ........... ........... ........... ........... ...........
59121.............. Treat ectopic pregnancy... .................. C................. ........... ........... ........... ........... ...........
59130.............. Treat ectopic pregnancy... .................. C................. ........... ........... ........... ........... ...........
59135.............. Treat ectopic pregnancy... .................. C................. ........... ........... ........... ........... ...........
59136.............. Treat ectopic pregnancy... .................. C................. ........... ........... ........... ........... ...........
59140.............. Treat ectopic pregnancy... .................. C................. ........... ........... ........... ........... ...........
59150.............. Treat ectopic pregnancy... .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
59151.............. Treat ectopic pregnancy... .................. T................. 0131 45.5317 $2,900.10 $1,001.89 $580.02
59160.............. D & c after delivery...... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59200.............. Insert cervical dilator... .................. T................. 0189 2.7584 $175.69 ........... $35.14
59300.............. Episiotomy or vaginal .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
repair.
59320.............. Revision of cervix........ CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59325.............. Revision of cervix........ .................. C................. ........... ........... ........... ........... ...........
59350.............. Repair of uterus.......... .................. C................. ........... ........... ........... ........... ...........
59400.............. Obstetrical care.......... .................. B................. ........... ........... ........... ........... ...........
59409.............. Obstetrical care.......... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59410.............. Obstetrical care.......... .................. B................. ........... ........... ........... ........... ...........
59412.............. Antepartum manipulation... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59414.............. Deliver placenta.......... .................. T................. 0193 19.0203 $1,211.48 ........... $242.30
59425.............. Antepartum care only...... .................. B................. ........... ........... ........... ........... ...........
59426.............. Antepartum care only...... .................. B................. ........... ........... ........... ........... ...........
59430.............. Care after delivery....... .................. B................. ........... ........... ........... ........... ...........
59510.............. Cesarean delivery......... .................. B................. ........... ........... ........... ........... ...........
[[Page 67059]]
59514.............. Cesarean delivery only.... .................. C................. ........... ........... ........... ........... ...........
59515.............. Cesarean delivery......... .................. B................. ........... ........... ........... ........... ...........
59525.............. Remove uterus after .................. C................. ........... ........... ........... ........... ...........
cesarean.
59610.............. Vbac delivery............. .................. B................. ........... ........... ........... ........... ...........
59612.............. Vbac delivery only........ CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59614.............. Vbac care after delivery.. .................. B................. ........... ........... ........... ........... ...........
59618.............. Attempted vbac delivery... .................. B................. ........... ........... ........... ........... ...........
59620.............. Attempted vbac delivery .................. C................. ........... ........... ........... ........... ...........
only.
59622.............. Attempted vbac after care. .................. B................. ........... ........... ........... ........... ...........
59812.............. Treatment of miscarriage.. CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59820.............. Care of miscarriage....... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59821.............. Treatment of miscarriage.. CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59830.............. Treat uterus infection.... .................. C................. ........... ........... ........... ........... ...........
59840.............. Abortion.................. CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59841.............. Abortion.................. CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59850.............. Abortion.................. .................. C................. ........... ........... ........... ........... ...........
59851.............. Abortion.................. .................. C................. ........... ........... ........... ........... ...........
59852.............. Abortion.................. .................. C................. ........... ........... ........... ........... ...........
59855.............. Abortion.................. .................. C................. ........... ........... ........... ........... ...........
59856.............. Abortion.................. .................. C................. ........... ........... ........... ........... ...........
59857.............. Abortion.................. .................. C................. ........... ........... ........... ........... ...........
59866.............. Abortion (mpr)............ CH................ T................. 0189 2.7584 $175.69 ........... $35.14
59870.............. Evacuate mole of uterus... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59871.............. Remove cerclage suture.... CH................ T................. 0193 19.0203 $1,211.48 ........... $242.30
59897.............. Fetal invas px w/us....... CH................ T................. 0189 2.7584 $175.69 ........... $35.14
59898.............. Laparo proc, ob care/ .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
deliver.
59899.............. Maternity care procedure.. CH................ T................. 0191 0.1309 $8.34 $2.36 $1.67
60000.............. Drain thyroid/tongue cyst. .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
60001.............. Aspirate/inject thyriod CH................ D................. ........... ........... ........... ........... ...........
cyst.
6005F.............. Care level rationale doc.. .................. M................. ........... ........... ........... ........... ...........
60100.............. Biopsy of thyroid......... .................. T................. 0004 4.3270 $275.60 ........... $55.12
6010F.............. Dysphag test done b/4 .................. M................. ........... ........... ........... ........... ...........
eating.
6015F.............. Dysphag test done b/4 .................. M................. ........... ........... ........... ........... ...........
eating.
60200.............. Remove thyroid lesion..... .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
6020F.............. Npo (nothing-mouth) .................. M................. ........... ........... ........... ........... ...........
ordered.
60210.............. Partial thyroid excision.. .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
60212.............. Partial thyroid excision.. .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
60220.............. Partial removal of thyroid .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
60225.............. Partial removal of thyroid .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
60240.............. Removal of thyroid........ .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
60252.............. Removal of thyroid........ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
60254.............. Extensive thyroid surgery. .................. C................. ........... ........... ........... ........... ...........
60260.............. Repeat thyroid surgery.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
60270.............. Removal of thyroid........ .................. C................. ........... ........... ........... ........... ...........
60271.............. Removal of thyroid........ CH................ T................. 0256 39.8776 $2,539.96 ........... $507.99
60280.............. Remove thyroid duct lesion .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
60281.............. Remove thyroid duct lesion .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
60300.............. Aspir/inj thyroid cyst.... NI................ T................. 0004 4.3270 $275.60 ........... $55.12
6030F.............. Max sterile barriers NI................ M................. ........... ........... ........... ........... ...........
follw'd.
60500.............. Explore parathyroid glands .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
60502.............. Re-explore parathyroids... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
60505.............. Explore parathyroid glands .................. C................. ........... ........... ........... ........... ...........
60512.............. Autotransplant parathyroid .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
60520.............. Removal of thymus gland... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
60521.............. Removal of thymus gland... .................. C................. ........... ........... ........... ........... ...........
60522.............. Removal of thymus gland... .................. C................. ........... ........... ........... ........... ...........
60540.............. Explore adrenal gland..... .................. C................. ........... ........... ........... ........... ...........
60545.............. Explore adrenal gland..... .................. C................. ........... ........... ........... ........... ...........
60600.............. Remove carotid body lesion .................. C................. ........... ........... ........... ........... ...........
60605.............. Remove carotid body lesion .................. C................. ........... ........... ........... ........... ...........
60650.............. Laparoscopy adrenalectomy. .................. C................. ........... ........... ........... ........... ...........
60659.............. Laparo proc, endocrine.... .................. T................. 0130 34.3958 $2,190.81 $659.53 $438.16
60699.............. Endocrine surgery .................. T................. 0114 44.3240 $2,823.17 ........... $564.63
procedure.
61000.............. Remove cranial cavity .................. T................. 0212 8.5263 $543.07 ........... $108.61
fluid.
61001.............. Remove cranial cavity .................. T................. 0212 8.5263 $543.07 ........... $108.61
fluid.
61020.............. Remove brain cavity fluid. .................. T................. 0212 8.5263 $543.07 ........... $108.61
61026.............. Injection into brain canal .................. T................. 0212 8.5263 $543.07 ........... $108.61
61050.............. Remove brain canal fluid.. .................. T................. 0212 8.5263 $543.07 ........... $108.61
61055.............. Injection into brain canal .................. T................. 0212 8.5263 $543.07 ........... $108.61
61070.............. Brain canal shunt CH................ T................. 0121 3.2383 $206.26 $43.80 $41.25
procedure.
61105.............. Twist drill hole.......... .................. C................. ........... ........... ........... ........... ...........
61107.............. Drill skull for .................. C................. ........... ........... ........... ........... ...........
implantation.
61108.............. Drill skull for drainage.. .................. C................. ........... ........... ........... ........... ...........
61120.............. Burr hole for puncture.... .................. C................. ........... ........... ........... ........... ...........
61140.............. Pierce skull for biopsy... .................. C................. ........... ........... ........... ........... ...........
61150.............. Pierce skull for drainage. .................. C................. ........... ........... ........... ........... ...........
61151.............. Pierce skull for drainage. .................. C................. ........... ........... ........... ........... ...........
61154.............. Pierce skull & remove clot .................. C................. ........... ........... ........... ........... ...........
61156.............. Pierce skull for drainage. .................. C................. ........... ........... ........... ........... ...........
61210.............. Pierce skull, implant .................. C................. ........... ........... ........... ........... ...........
device.
[[Page 67060]]
61215.............. Insert brain-fluid device. .................. T................. 0224 36.2768 $2,310.61 ........... $462.12
61250.............. Pierce skull & explore.... .................. C................. ........... ........... ........... ........... ...........
61253.............. Pierce skull & explore.... .................. C................. ........... ........... ........... ........... ...........
61304.............. Open skull for exploration .................. C................. ........... ........... ........... ........... ...........
61305.............. Open skull for exploration .................. C................. ........... ........... ........... ........... ...........
61312.............. Open skull for drainage... .................. C................. ........... ........... ........... ........... ...........
61313.............. Open skull for drainage... .................. C................. ........... ........... ........... ........... ...........
61314.............. Open skull for drainage... .................. C................. ........... ........... ........... ........... ...........
61315.............. Open skull for drainage... .................. C................. ........... ........... ........... ........... ...........
61316.............. Implt cran bone flap to .................. C................. ........... ........... ........... ........... ...........
abdo.
61320.............. Open skull for drainage... .................. C................. ........... ........... ........... ........... ...........
61321.............. Open skull for drainage... .................. C................. ........... ........... ........... ........... ...........
61322.............. Decompressive craniotomy.. .................. C................. ........... ........... ........... ........... ...........
61323.............. Decompressive lobectomy... .................. C................. ........... ........... ........... ........... ...........
61330.............. Decompress eye socket..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
61332.............. Explore/biopsy eye socket. .................. C................. ........... ........... ........... ........... ...........
61333.............. Explore orbit/remove .................. C................. ........... ........... ........... ........... ...........
lesion.
61334.............. Explore orbit/remove .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
object.
61340.............. Subtemporal decompression. .................. C................. ........... ........... ........... ........... ...........
61343.............. Incise skull (press .................. C................. ........... ........... ........... ........... ...........
relief).
61345.............. Relieve cranial pressure.. .................. C................. ........... ........... ........... ........... ...........
61440.............. Incise skull for surgery.. .................. C................. ........... ........... ........... ........... ...........
61450.............. Incise skull for surgery.. .................. C................. ........... ........... ........... ........... ...........
61458.............. Incise skull for brain .................. C................. ........... ........... ........... ........... ...........
wound.
61460.............. Incise skull for surgery.. .................. C................. ........... ........... ........... ........... ...........
61470.............. Incise skull for surgery.. .................. C................. ........... ........... ........... ........... ...........
61480.............. Incise skull for surgery.. .................. C................. ........... ........... ........... ........... ...........
61490.............. Incise skull for surgery.. .................. C................. ........... ........... ........... ........... ...........
61500.............. Removal of skull lesion... .................. C................. ........... ........... ........... ........... ...........
61501.............. Remove infected skull bone .................. C................. ........... ........... ........... ........... ...........
61510.............. Removal of brain lesion... .................. C................. ........... ........... ........... ........... ...........
61512.............. Remove brain lining lesion .................. C................. ........... ........... ........... ........... ...........
61514.............. Removal of brain abscess.. .................. C................. ........... ........... ........... ........... ...........
61516.............. Removal of brain lesion... .................. C................. ........... ........... ........... ........... ...........
61517.............. Implt brain chemotx add-on .................. C................. ........... ........... ........... ........... ...........
61518.............. Removal of brain lesion... .................. C................. ........... ........... ........... ........... ...........
61519.............. Remove brain lining lesion .................. C................. ........... ........... ........... ........... ...........
61520.............. Removal of brain lesion... .................. C................. ........... ........... ........... ........... ...........
61521.............. Removal of brain lesion... .................. C................. ........... ........... ........... ........... ...........
61522.............. Removal of brain abscess.. .................. C................. ........... ........... ........... ........... ...........
61524.............. Removal of brain lesion... .................. C................. ........... ........... ........... ........... ...........
61526.............. Removal of brain lesion... .................. C................. ........... ........... ........... ........... ...........
61530.............. Removal of brain lesion... .................. C................. ........... ........... ........... ........... ...........
61531.............. Implant brain electrodes.. .................. C................. ........... ........... ........... ........... ...........
61533.............. Implant brain electrodes.. .................. C................. ........... ........... ........... ........... ...........
61534.............. Removal of brain lesion... .................. C................. ........... ........... ........... ........... ...........
61535.............. Remove brain electrodes... .................. C................. ........... ........... ........... ........... ...........
61536.............. Removal of brain lesion... .................. C................. ........... ........... ........... ........... ...........
61537.............. Removal of brain tissue... .................. C................. ........... ........... ........... ........... ...........
61538.............. Removal of brain tissue... .................. C................. ........... ........... ........... ........... ...........
61539.............. Removal of brain tissue... .................. C................. ........... ........... ........... ........... ...........
61540.............. Removal of brain tissue... .................. C................. ........... ........... ........... ........... ...........
61541.............. Incision of brain tissue.. .................. C................. ........... ........... ........... ........... ...........
61542.............. Removal of brain tissue... .................. C................. ........... ........... ........... ........... ...........
61543.............. Removal of brain tissue... .................. C................. ........... ........... ........... ........... ...........
61544.............. Remove & treat brain .................. C................. ........... ........... ........... ........... ...........
lesion.
61545.............. Excision of brain tumor... .................. C................. ........... ........... ........... ........... ...........
61546.............. Removal of pituitary gland .................. C................. ........... ........... ........... ........... ...........
61548.............. Removal of pituitary gland .................. C................. ........... ........... ........... ........... ...........
61550.............. Release of skull seams.... .................. C................. ........... ........... ........... ........... ...........
61552.............. Release of skull seams.... .................. C................. ........... ........... ........... ........... ...........
61556.............. Incise skull/sutures...... .................. C................. ........... ........... ........... ........... ...........
61557.............. Incise skull/sutures...... .................. C................. ........... ........... ........... ........... ...........
61558.............. Excision of skull/sutures. .................. C................. ........... ........... ........... ........... ...........
61559.............. Excision of skull/sutures. .................. C................. ........... ........... ........... ........... ...........
61563.............. Excision of skull tumor... .................. C................. ........... ........... ........... ........... ...........
61564.............. Excision of skull tumor... .................. C................. ........... ........... ........... ........... ...........
61566.............. Removal of brain tissue... .................. C................. ........... ........... ........... ........... ...........
61567.............. Incision of brain tissue.. .................. C................. ........... ........... ........... ........... ...........
61570.............. Remove foreign body, brain .................. C................. ........... ........... ........... ........... ...........
61571.............. Incise skull for brain .................. C................. ........... ........... ........... ........... ...........
wound.
61575.............. Skull base/brainstem .................. C................. ........... ........... ........... ........... ...........
surgery.
61576.............. Skull base/brainstem .................. C................. ........... ........... ........... ........... ...........
surgery.
61580.............. Craniofacial approach, .................. C................. ........... ........... ........... ........... ...........
skull.
61581.............. Craniofacial approach, .................. C................. ........... ........... ........... ........... ...........
skull.
61582.............. Craniofacial approach, .................. C................. ........... ........... ........... ........... ...........
skull.
61583.............. Craniofacial approach, .................. C................. ........... ........... ........... ........... ...........
skull.
61584.............. Orbitocranial approach/ .................. C................. ........... ........... ........... ........... ...........
skull.
61585.............. Orbitocranial approach/ .................. C................. ........... ........... ........... ........... ...........
skull.
61586.............. Resect nasopharynx, skull. .................. C................. ........... ........... ........... ........... ...........
[[Page 67061]]
61590.............. Infratemporal approach/ .................. C................. ........... ........... ........... ........... ...........
skull.
61591.............. Infratemporal approach/ .................. C................. ........... ........... ........... ........... ...........
skull.
61592.............. Orbitocranial approach/ .................. C................. ........... ........... ........... ........... ...........
skull.
61595.............. Transtemporal approach/ .................. C................. ........... ........... ........... ........... ...........
skull.
61596.............. Transcochlear approach/ .................. C................. ........... ........... ........... ........... ...........
skull.
61597.............. Transcondylar approach/ .................. C................. ........... ........... ........... ........... ...........
skull.
61598.............. Transpetrosal approach/ .................. C................. ........... ........... ........... ........... ...........
skull.
61600.............. Resect/excise cranial .................. C................. ........... ........... ........... ........... ...........
lesion.
61601.............. Resect/excise cranial .................. C................. ........... ........... ........... ........... ...........
lesion.
61605.............. Resect/excise cranial .................. C................. ........... ........... ........... ........... ...........
lesion.
61606.............. Resect/excise cranial .................. C................. ........... ........... ........... ........... ...........
lesion.
61607.............. Resect/excise cranial .................. C................. ........... ........... ........... ........... ...........
lesion.
61608.............. Resect/excise cranial .................. C................. ........... ........... ........... ........... ...........
lesion.
61609.............. Transect artery, sinus.... .................. C................. ........... ........... ........... ........... ...........
61610.............. Transect artery, sinus.... .................. C................. ........... ........... ........... ........... ...........
61611.............. Transect artery, sinus.... .................. C................. ........... ........... ........... ........... ...........
61612.............. Transect artery, sinus.... .................. C................. ........... ........... ........... ........... ...........
61613.............. Remove aneurysm, sinus.... .................. C................. ........... ........... ........... ........... ...........
61615.............. Resect/excise lesion, .................. C................. ........... ........... ........... ........... ...........
skull.
61616.............. Resect/excise lesion, .................. C................. ........... ........... ........... ........... ...........
skull.
61618.............. Repair dura............... .................. C................. ........... ........... ........... ........... ...........
61619.............. Repair dura............... .................. C................. ........... ........... ........... ........... ...........
61623.............. Endovasc tempory vessel CH................ T................. 0082 87.5137 $5,574.10 ........... $1,114.82
occl.
61624.............. Transcath occlusion, cns.. .................. C................. ........... ........... ........... ........... ...........
61626.............. Transcath occlusion, non- CH................ T................. 0082 87.5137 $5,574.10 ........... $1,114.82
cns.
61630.............. Intracranial angioplasty.. .................. E................. ........... ........... ........... ........... ...........
61635.............. Intracran angioplsty w/ .................. E................. ........... ........... ........... ........... ...........
stent.
61640.............. Dilate ic vasospasm, init. .................. E................. ........... ........... ........... ........... ...........
61641.............. Dilate ic vasospasm add-on .................. E................. ........... ........... ........... ........... ...........
61642.............. Dilate ic vasospasm add-on .................. E................. ........... ........... ........... ........... ...........
61680.............. Intracranial vessel .................. C................. ........... ........... ........... ........... ...........
surgery.
61682.............. Intracranial vessel .................. C................. ........... ........... ........... ........... ...........
surgery.
61684.............. Intracranial vessel .................. C................. ........... ........... ........... ........... ...........
surgery.
61686.............. Intracranial vessel .................. C................. ........... ........... ........... ........... ...........
surgery.
61690.............. Intracranial vessel .................. C................. ........... ........... ........... ........... ...........
surgery.
61692.............. Intracranial vessel .................. C................. ........... ........... ........... ........... ...........
surgery.
61697.............. Brain aneurysm repr, .................. C................. ........... ........... ........... ........... ...........
complx.
61698.............. Brain aneurysm repr, .................. C................. ........... ........... ........... ........... ...........
complx.
61700.............. Brain aneurysm repr, .................. C................. ........... ........... ........... ........... ...........
simple.
61702.............. Inner skull vessel surgery .................. C................. ........... ........... ........... ........... ...........
61703.............. Clamp neck artery......... .................. C................. ........... ........... ........... ........... ...........
61705.............. Revise circulation to head .................. C................. ........... ........... ........... ........... ...........
61708.............. Revise circulation to head .................. C................. ........... ........... ........... ........... ...........
61710.............. Revise circulation to head .................. C................. ........... ........... ........... ........... ...........
61711.............. Fusion of skull arteries.. .................. C................. ........... ........... ........... ........... ...........
61720.............. Incise skull/brain surgery .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
61735.............. Incise skull/brain surgery .................. C................. ........... ........... ........... ........... ...........
61750.............. Incise skull/brain biopsy. .................. C................. ........... ........... ........... ........... ...........
61751.............. Brain biopsy w/ct/mr guide .................. C................. ........... ........... ........... ........... ...........
61760.............. Implant brain electrodes.. .................. C................. ........... ........... ........... ........... ...........
61770.............. Incise skull for treatment CH................ T................. 0221 33.2707 $2,119.14 $463.62 $423.83
61790.............. Treat trigeminal nerve.... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
61791.............. Treat trigeminal tract.... CH................ T................. 0203 14.4879 $922.79 $240.33 $184.56
61793.............. Focus radiation beam...... .................. B................. ........... ........... ........... ........... ...........
61795.............. Brain surgery using CH................ N................. ........... ........... ........... ........... ...........
computer.
61850.............. Implant neuroelectrodes... .................. C................. ........... ........... ........... ........... ...........
61860.............. Implant neuroelectrodes... .................. C................. ........... ........... ........... ........... ...........
61863.............. Implant neuroelectrode.... .................. C................. ........... ........... ........... ........... ...........
61864.............. Implant neuroelectrde, .................. C................. ........... ........... ........... ........... ...........
addl.
61867.............. Implant neuroelectrode.... .................. C................. ........... ........... ........... ........... ...........
61868.............. Implant neuroelectrde, .................. C................. ........... ........... ........... ........... ...........
add'l.
61870.............. Implant neuroelectrodes... .................. C................. ........... ........... ........... ........... ...........
61875.............. Implant neuroelectrodes... .................. C................. ........... ........... ........... ........... ...........
61880.............. Revise/remove .................. T................. 0687 22.4734 $1,431.42 $438.47 $286.28
neuroelectrode.
61885.............. Insrt/redo neurostim 1 .................. S................. 0039 186.4739 $11,877.27 ........... $2,375.45
array.
61886.............. Implant neurostim arrays.. CH................ S................. 0315 270.0190 $17,198.59 ........... $3,439.72
61888.............. Revise/remove .................. T................. 0688 34.4166 $2,192.13 $874.57 $438.43
neuroreceiver.
62000.............. Treat skull fracture...... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
62005.............. Treat skull fracture...... .................. C................. ........... ........... ........... ........... ...........
62010.............. Treatment of head injury.. .................. C................. ........... ........... ........... ........... ...........
62100.............. Repair brain fluid leakage .................. C................. ........... ........... ........... ........... ...........
62115.............. Reduction of skull defect. .................. C................. ........... ........... ........... ........... ...........
62116.............. Reduction of skull defect. .................. C................. ........... ........... ........... ........... ...........
62117.............. Reduction of skull defect. .................. C................. ........... ........... ........... ........... ...........
62120.............. Repair skull cavity lesion .................. C................. ........... ........... ........... ........... ...........
62121.............. Incise skull repair....... .................. C................. ........... ........... ........... ........... ...........
62140.............. Repair of skull defect.... .................. C................. ........... ........... ........... ........... ...........
62141.............. Repair of skull defect.... .................. C................. ........... ........... ........... ........... ...........
62142.............. Remove skull plate/flap... .................. C................. ........... ........... ........... ........... ...........
62143.............. Replace skull plate/flap.. .................. C................. ........... ........... ........... ........... ...........
[[Page 67062]]
62145.............. Repair of skull & brain... .................. C................. ........... ........... ........... ........... ...........
62146.............. Repair of skull with graft .................. C................. ........... ........... ........... ........... ...........
62147.............. Repair of skull with graft .................. C................. ........... ........... ........... ........... ...........
62148.............. Retr bone flap to fix .................. C................. ........... ........... ........... ........... ...........
skull.
62160.............. Neuroendoscopy add-on..... CH................ N................. ........... ........... ........... ........... ...........
62161.............. Dissect brain w/scope..... .................. C................. ........... ........... ........... ........... ...........
62162.............. Remove colloid cyst w/ .................. C................. ........... ........... ........... ........... ...........
scope.
62163.............. Neuroendoscopy w/fb .................. C................. ........... ........... ........... ........... ...........
removal.
62164.............. Remove brain tumor w/scope .................. C................. ........... ........... ........... ........... ...........
62165.............. Remove pituit tumor w/ .................. C................. ........... ........... ........... ........... ...........
scope.
62180.............. Establish brain cavity .................. C................. ........... ........... ........... ........... ...........
shunt.
62190.............. Establish brain cavity .................. C................. ........... ........... ........... ........... ...........
shunt.
62192.............. Establish brain cavity .................. C................. ........... ........... ........... ........... ...........
shunt.
62194.............. Replace/irrigate catheter. CH................ T................. 0212 8.5263 $543.07 ........... $108.61
62200.............. Establish brain cavity .................. C................. ........... ........... ........... ........... ...........
shunt.
62201.............. Brain cavity shunt w/scope .................. C................. ........... ........... ........... ........... ...........
62220.............. Establish brain cavity .................. C................. ........... ........... ........... ........... ...........
shunt.
62223.............. Establish brain cavity .................. C................. ........... ........... ........... ........... ...........
shunt.
62225.............. Replace/irrigate catheter. .................. T................. 0427 15.3545 $977.99 ........... $195.60
62230.............. Replace/revise brain shunt .................. T................. 0224 36.2768 $2,310.61 ........... $462.12
62252.............. Csf shunt reprogram....... .................. S................. 0691 2.3269 $148.21 $50.49 $29.64
62256.............. Remove brain cavity shunt. .................. C................. ........... ........... ........... ........... ...........
62258.............. Replace brain cavity shunt .................. C................. ........... ........... ........... ........... ...........
62263.............. Epidural lysis mult .................. T................. 0203 14.4879 $922.79 $240.33 $184.56
sessions.
62264.............. Epidural lysis on single .................. T................. 0203 14.4879 $922.79 $240.33 $184.56
day.
62268.............. Drain spinal cord cyst.... .................. T................. 0212 8.5263 $543.07 ........... $108.61
62269.............. Needle biopsy, spinal cord .................. T................. 0685 9.3354 $594.61 ........... $118.92
62270.............. Spinal fluid tap, CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
diagnostic.
62272.............. Drain cerebro spinal fluid CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
62273.............. Inject epidural patch..... .................. T................. 0206 4.0964 $260.92 $56.01 $52.18
62280.............. Treat spinal cord lesion.. .................. T................. 0207 7.0546 $449.34 ........... $89.87
62281.............. Treat spinal cord lesion.. .................. T................. 0207 7.0546 $449.34 ........... $89.87
62282.............. Treat spinal canal lesion. .................. T................. 0207 7.0546 $449.34 ........... $89.87
62284.............. Injection for myelogram... .................. N................. ........... ........... ........... ........... ...........
62287.............. Percutaneous diskectomy... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
62290.............. Inject for spine disk x- .................. N................. ........... ........... ........... ........... ...........
ray.
62291.............. Inject for spine disk x- .................. N................. ........... ........... ........... ........... ...........
ray.
62292.............. Injection into disk lesion .................. T................. 0212 8.5263 $543.07 ........... $108.61
62294.............. Injection into spinal .................. T................. 0212 8.5263 $543.07 ........... $108.61
artery.
62310.............. Inject spine c/t.......... .................. T................. 0207 7.0546 $449.34 ........... $89.87
62311.............. Inject spine l/s (cd)..... .................. T................. 0207 7.0546 $449.34 ........... $89.87
62318.............. Inject spine w/cath, c/t.. .................. T................. 0207 7.0546 $449.34 ........... $89.87
62319.............. Inject spine w/cath l/s .................. T................. 0207 7.0546 $449.34 ........... $89.87
(cd).
62350.............. Implant spinal canal cath. CH................ T................. 0224 36.2768 $2,310.61 ........... $462.12
62351.............. Implant spinal canal cath. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
62355.............. Remove spinal canal .................. T................. 0203 14.4879 $922.79 $240.33 $184.56
catheter.
62360.............. Insert spine infusion CH................ T................. 0224 36.2768 $2,310.61 ........... $462.12
device.
62361.............. Implant spine infusion .................. T................. 0227 183.8928 $11,712.87 ........... $2,342.57
pump.
62362.............. Implant spine infusion .................. T................. 0227 183.8928 $11,712.87 ........... $2,342.57
pump.
62365.............. Remove spine infusion .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
device.
62367.............. Analyze spine infusion .................. S................. 0691 2.3269 $148.21 $50.49 $29.64
pump.
62368.............. Analyze spine infusion .................. S................. 0691 2.3269 $148.21 $50.49 $29.64
pump.
63001.............. Removal of spinal lamina.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63003.............. Removal of spinal lamina.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63005.............. Removal of spinal lamina.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63011.............. Removal of spinal lamina.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63012.............. Removal of spinal lamina.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63015.............. Removal of spinal lamina.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63016.............. Removal of spinal lamina.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63017.............. Removal of spinal lamina.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63020.............. Neck spine disk surgery... .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63030.............. Low back disk surgery..... .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63035.............. Spinal disk surgery add-on .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63040.............. Laminotomy, single .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
cervical.
63042.............. Laminotomy, single lumbar. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63043.............. Laminotomy, add'l cervical .................. C................. ........... ........... ........... ........... ...........
63044.............. Laminotomy, add'l lumbar.. .................. C................. ........... ........... ........... ........... ...........
63045.............. Removal of spinal lamina.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63046.............. Removal of spinal lamina.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63047.............. Removal of spinal lamina.. .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63048.............. Remove spinal lamina add- .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
on.
63050.............. Cervical laminoplasty..... .................. C................. ........... ........... ........... ........... ...........
63051.............. C-laminoplasty w/graft/ .................. C................. ........... ........... ........... ........... ...........
plate.
63055.............. Decompress spinal cord.... .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63056.............. Decompress spinal cord.... .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63057.............. Decompress spine cord add- .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
on.
63064.............. Decompress spinal cord.... .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63066.............. Decompress spine cord add- .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
on.
63075.............. Neck spine disk surgery... .................. T................. 0208 46.7724 $2,979.12 ........... $595.82
63076.............. Neck spine disk surgery... .................. C................. ........... ........... ........... ........... ...........
[[Page 67063]]
63077.............. Spine disk surgery, thorax .................. C................. ........... ........... ........... ........... ...........
63078.............. Spine disk surgery, thorax .................. C................. ........... ........... ........... ........... ...........
63081.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63082.............. Remove vertebral body add- .................. C................. ........... ........... ........... ........... ...........
on.
63085.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63086.............. Remove vertebral body add- .................. C................. ........... ........... ........... ........... ...........
on.
63087.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63088.............. Remove vertebral body add- .................. C................. ........... ........... ........... ........... ...........
on.
63090.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63091.............. Remove vertebral body add- .................. C................. ........... ........... ........... ........... ...........
on.
63101.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63102.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63103.............. Remove vertebral body add- .................. C................. ........... ........... ........... ........... ...........
on.
63170.............. Incise spinal cord .................. C................. ........... ........... ........... ........... ...........
tract(s).
63172.............. Drainage of spinal cyst... .................. C................. ........... ........... ........... ........... ...........
63173.............. Drainage of spinal cyst... .................. C................. ........... ........... ........... ........... ...........
63180.............. Revise spinal cord .................. C................. ........... ........... ........... ........... ...........
ligaments.
63182.............. Revise spinal cord .................. C................. ........... ........... ........... ........... ...........
ligaments.
63185.............. Incise spinal column/ .................. C................. ........... ........... ........... ........... ...........
nerves.
63190.............. Incise spinal column/ .................. C................. ........... ........... ........... ........... ...........
nerves.
63191.............. Incise spinal column/ .................. C................. ........... ........... ........... ........... ...........
nerves.
63194.............. Incise spinal column & .................. C................. ........... ........... ........... ........... ...........
cord.
63195.............. Incise spinal column & .................. C................. ........... ........... ........... ........... ...........
cord.
63196.............. Incise spinal column & .................. C................. ........... ........... ........... ........... ...........
cord.
63197.............. Incise spinal column & .................. C................. ........... ........... ........... ........... ...........
cord.
63198.............. Incise spinal column & .................. C................. ........... ........... ........... ........... ...........
cord.
63199.............. Incise spinal column & .................. C................. ........... ........... ........... ........... ...........
cord.
63200.............. Release of spinal cord.... .................. C................. ........... ........... ........... ........... ...........
63250.............. Revise spinal cord vessels .................. C................. ........... ........... ........... ........... ...........
63251.............. Revise spinal cord vessels .................. C................. ........... ........... ........... ........... ...........
63252.............. Revise spinal cord vessels .................. C................. ........... ........... ........... ........... ...........
63265.............. Excise intraspinal lesion. .................. C................. ........... ........... ........... ........... ...........
63266.............. Excise intraspinal lesion. .................. C................. ........... ........... ........... ........... ...........
63267.............. Excise intraspinal lesion. .................. C................. ........... ........... ........... ........... ...........
63268.............. Excise intraspinal lesion. .................. C................. ........... ........... ........... ........... ...........
63270.............. Excise intraspinal lesion. .................. C................. ........... ........... ........... ........... ...........
63271.............. Excise intraspinal lesion. .................. C................. ........... ........... ........... ........... ...........
63272.............. Excise intraspinal lesion. .................. C................. ........... ........... ........... ........... ...........
63273.............. Excise intraspinal lesion. .................. C................. ........... ........... ........... ........... ...........
63275.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63276.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63277.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63278.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63280.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63281.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63282.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63283.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63285.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63286.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63287.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63290.............. Biopsy/excise spinal tumor .................. C................. ........... ........... ........... ........... ...........
63295.............. Repair of laminectomy .................. C................. ........... ........... ........... ........... ...........
defect.
63300.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63301.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63302.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63303.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63304.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63305.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63306.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63307.............. Removal of vertebral body. .................. C................. ........... ........... ........... ........... ...........
63308.............. Remove vertebral body add- .................. C................. ........... ........... ........... ........... ...........
on.
63600.............. Remove spinal cord lesion. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
63610.............. Stimulation of spinal cord .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
63615.............. Remove lesion of spinal .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
cord.
63650.............. Implant neuroelectrodes... .................. S................. 0040 63.7866 $4,062.82 ........... $812.56
63655.............. Implant neuroelectrodes... .................. S................. 0061 82.8597 $5,277.67 ........... $1,055.53
63660.............. Revise/remove .................. T................. 0687 22.4734 $1,431.42 $438.47 $286.28
neuroelectrode.
63685.............. Insrt/redo spine n CH................ S................. 0222 240.7990 $15,337.45 ........... $3,067.49
generator.
63688.............. Revise/remove .................. T................. 0688 34.4166 $2,192.13 $874.57 $438.43
neuroreceiver.
63700.............. Repair of spinal .................. C................. ........... ........... ........... ........... ...........
herniation.
63702.............. Repair of spinal .................. C................. ........... ........... ........... ........... ...........
herniation.
63704.............. Repair of spinal .................. C................. ........... ........... ........... ........... ...........
herniation.
63706.............. Repair of spinal .................. C................. ........... ........... ........... ........... ...........
herniation.
63707.............. Repair spinal fluid .................. C................. ........... ........... ........... ........... ...........
leakage.
63709.............. Repair spinal fluid .................. C................. ........... ........... ........... ........... ...........
leakage.
63710.............. Graft repair of spine .................. C................. ........... ........... ........... ........... ...........
defect.
63740.............. Install spinal shunt...... .................. C................. ........... ........... ........... ........... ...........
63741.............. Install spinal shunt...... CH................ T................. 0224 36.2768 $2,310.61 ........... $462.12
63744.............. Revision of spinal shunt.. CH................ T................. 0224 36.2768 $2,310.61 ........... $462.12
63746.............. Removal of spinal shunt... .................. T................. 0109 5.6614 $360.60 ........... $72.12
[[Page 67064]]
64400.............. N block inj, trigeminal... .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
64402.............. N block inj, facial....... .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
64405.............. N block inj, occipital.... CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
64408.............. N block inj, vagus........ CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
64410.............. N block inj, phrenic...... CH................ T................. 0207 7.0546 $449.34 ........... $89.87
64412.............. N block inj, spinal CH................ T................. 0207 7.0546 $449.34 ........... $89.87
accessor.
64413.............. N block inj, cervical CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
plexus.
64415.............. N block inj, brachial CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
plexus.
64416.............. N block cont infuse, b CH................ T................. 0207 7.0546 $449.34 ........... $89.87
plex.
64417.............. N block inj, axillary..... CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
64418.............. N block inj, suprascapular CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
64420.............. N block inj, intercost, CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
sng.
64421.............. N block inj, intercost, .................. T................. 0206 4.0964 $260.92 $56.01 $52.18
mlt.
64425.............. N block inj, ilio-ing/ CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
hypogi.
64430.............. N block inj, pudendal..... CH................ T................. 0207 7.0546 $449.34 ........... $89.87
64435.............. N block inj, paracervical. CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
64445.............. N block inj, sciatic, sng. CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
64446.............. N blk inj, sciatic, cont CH................ T................. 0203 14.4879 $922.79 $240.33 $184.56
inf.
64447.............. N block inj fem, single... CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
64448.............. N block inj fem, cont inf. CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
64449.............. N block inj, lumbar plexus CH................ T................. 0207 7.0546 $449.34 ........... $89.87
64450.............. N block, other peripheral. CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
64470.............. Inj paravertebral c/t..... .................. T................. 0207 7.0546 $449.34 ........... $89.87
64472.............. Inj paravertebral c/t add- .................. T................. 0206 4.0964 $260.92 $56.01 $52.18
on.
64475.............. Inj paravertebral l/s..... .................. T................. 0207 7.0546 $449.34 ........... $89.87
64476.............. Inj paravertebral l/s add- CH................ T................. 0204 2.3213 $147.85 $40.13 $29.57
on.
64479.............. Inj foramen epidural c/t.. .................. T................. 0207 7.0546 $449.34 ........... $89.87
64480.............. Inj foramen epidural add- CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
on.
64483.............. Inj foramen epidural l/s.. .................. T................. 0207 7.0546 $449.34 ........... $89.87
64484.............. Inj foramen epidural add- CH................ T................. 0206 4.0964 $260.92 $56.01 $52.18
on.
64505.............. N block, spenopalatine .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
gangl.
64508.............. N block, carotid sinus s/p .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
64510.............. N block, stellate ganglion .................. T................. 0207 7.0546 $449.34 ........... $89.87
64517.............. N block inj, hypogas plxs. CH................ T................. 0207 7.0546 $449.34 ........... $89.87
64520.............. N block, lumbar/thoracic.. .................. T................. 0207 7.0546 $449.34 ........... $89.87
64530.............. N block inj, celiac pelus. .................. T................. 0207 7.0546 $449.34 ........... $89.87
64550.............. Apply neurostimulator..... .................. A................. ........... ........... ........... ........... ...........
64553.............. Implant neuroelectrodes... .................. S................. 0225 220.7642 $14,061.35 ........... $2,812.27
64555.............. Implant neuroelectrodes... .................. S................. 0040 63.7866 $4,062.82 ........... $812.56
64560.............. Implant neuroelectrodes... .................. S................. 0040 63.7866 $4,062.82 ........... $812.56
64561.............. Implant neuroelectrodes... .................. S................. 0040 63.7866 $4,062.82 ........... $812.56
64565.............. Implant neuroelectrodes... .................. S................. 0040 63.7866 $4,062.82 ........... $812.56
64573.............. Implant neuroelectrodes... .................. S................. 0225 220.7642 $14,061.35 ........... $2,812.27
64575.............. Implant neuroelectrodes... .................. S................. 0061 82.8597 $5,277.67 ........... $1,055.53
64577.............. Implant neuroelectrodes... .................. S................. 0061 82.8597 $5,277.67 ........... $1,055.53
64580.............. Implant neuroelectrodes... .................. S................. 0061 82.8597 $5,277.67 ........... $1,055.53
64581.............. Implant neuroelectrodes... .................. S................. 0061 82.8597 $5,277.67 ........... $1,055.53
64585.............. Revise/remove .................. T................. 0687 22.4734 $1,431.42 $438.47 $286.28
neuroelectrode.
64590.............. Insrt/redo pn/gastr stimul CH................ S................. 0039 186.4739 $11,877.27 ........... $2,375.45
64595.............. Revise/rmv pn/gastr stimul .................. T................. 0688 34.4166 $2,192.13 $874.57 $438.43
64600.............. Injection treatment of .................. T................. 0203 14.4879 $922.79 $240.33 $184.56
nerve.
64605.............. Injection treatment of .................. T................. 0203 14.4879 $922.79 $240.33 $184.56
nerve.
64610.............. Injection treatment of .................. T................. 0203 14.4879 $922.79 $240.33 $184.56
nerve.
64612.............. Destroy nerve, face muscle .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
64613.............. Destroy nerve, neck muscle .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
64614.............. Destroy nerve, extrem musc .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
64620.............. Injection treatment of CH................ T................. 0207 7.0546 $449.34 ........... $89.87
nerve.
64622.............. Destr paravertebrl nerve l/ .................. T................. 0203 14.4879 $922.79 $240.33 $184.56
s.
64623.............. Destr paravertebral n add- .................. T................. 0207 7.0546 $449.34 ........... $89.87
on.
64626.............. Destr paravertebrl nerve c/ .................. T................. 0203 14.4879 $922.79 $240.33 $184.56
t.
64627.............. Destr paravertebral n add- CH................ T................. 0204 2.3213 $147.85 $40.13 $29.57
on.
64630.............. Injection treatment of CH................ T................. 0207 7.0546 $449.34 ........... $89.87
nerve.
64640.............. Injection treatment of CH................ T................. 0207 7.0546 $449.34 ........... $89.87
nerve.
64650.............. Chemodenerv eccrine glands .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
64653.............. Chemodenerv eccrine glands .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
64680.............. Injection treatment of CH................ T................. 0203 14.4879 $922.79 $240.33 $184.56
nerve.
64681.............. Injection treatment of .................. T................. 0203 14.4879 $922.79 $240.33 $184.56
nerve.
64702.............. Revise finger/toe nerve... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64704.............. Revise hand/foot nerve.... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64708.............. Revise arm/leg nerve...... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64712.............. Revision of sciatic nerve. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64713.............. Revision of arm nerve(s).. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64714.............. Revise low back nerve(s).. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64716.............. Revision of cranial nerve. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64718.............. Revise ulnar nerve at .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
elbow.
64719.............. Revise ulnar nerve at .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
wrist.
64721.............. Carpal tunnel surgery..... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64722.............. Relieve pressure on .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
nerve(s).
64726.............. Release foot/toe nerve.... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64727.............. Internal nerve revision... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
[[Page 67065]]
64732.............. Incision of brow nerve.... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64734.............. Incision of cheek nerve... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64736.............. Incision of chin nerve.... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64738.............. Incision of jaw nerve..... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64740.............. Incision of tongue nerve.. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64742.............. Incision of facial nerve.. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64744.............. Incise nerve, back of head .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64746.............. Incise diaphragm nerve.... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64752.............. Incision of vagus nerve... .................. C................. ........... ........... ........... ........... ...........
64755.............. Incision of stomach nerves .................. C................. ........... ........... ........... ........... ...........
64760.............. Incision of vagus nerve... .................. C................. ........... ........... ........... ........... ...........
64761.............. Incision of pelvis nerve.. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64763.............. Incise hip/thigh nerve.... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64766.............. Incise hip/thigh nerve.... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64771.............. Sever cranial nerve....... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64772.............. Incision of spinal nerve.. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64774.............. Remove skin nerve lesion.. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64776.............. Remove digit nerve lesion. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64778.............. Digit nerve surgery add-on .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64782.............. Remove limb nerve lesion.. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64783.............. Limb nerve surgery add-on. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64784.............. Remove nerve lesion....... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64786.............. Remove sciatic nerve .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
lesion.
64787.............. Implant nerve end......... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64788.............. Remove skin nerve lesion.. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64790.............. Removal of nerve lesion... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64792.............. Removal of nerve lesion... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64795.............. Biopsy of nerve........... .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64802.............. Remove sympathetic nerves. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64804.............. Remove sympathetic nerves. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64809.............. Remove sympathetic nerves. .................. C................. ........... ........... ........... ........... ...........
64818.............. Remove sympathetic nerves. .................. C................. ........... ........... ........... ........... ...........
64820.............. Remove sympathetic nerves. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64821.............. Remove sympathetic nerves. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
64822.............. Remove sympathetic nerves. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
64823.............. Remove sympathetic nerves. .................. T................. 0054 26.3105 $1,675.82 ........... $335.16
64831.............. Repair of digit nerve..... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64832.............. Repair nerve add-on....... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64834.............. Repair of hand or foot .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
nerve.
64835.............. Repair of hand or foot .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
nerve.
64836.............. Repair of hand or foot .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
nerve.
64837.............. Repair nerve add-on....... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64840.............. Repair of leg nerve....... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64856.............. Repair/transpose nerve.... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64857.............. Repair arm/leg nerve...... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64858.............. Repair sciatic nerve...... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64859.............. Nerve surgery............. .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64861.............. Repair of arm nerves...... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64862.............. Repair of low back nerves. .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64864.............. Repair of facial nerve.... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64865.............. Repair of facial nerve.... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64866.............. Fusion of facial/other .................. C................. ........... ........... ........... ........... ...........
nerve.
64868.............. Fusion of facial/other .................. C................. ........... ........... ........... ........... ...........
nerve.
64870.............. Fusion of facial/other .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
nerve.
64872.............. Subsequent repair of nerve .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64874.............. Repair & revise nerve add- .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
on.
64876.............. Repair nerve/shorten bone. .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64885.............. Nerve graft, head or neck. .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64886.............. Nerve graft, head or neck. .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64890.............. Nerve graft, hand or foot. .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64891.............. Nerve graft, hand or foot. .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64892.............. Nerve graft, arm or leg... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64893.............. Nerve graft, arm or leg... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64895.............. Nerve graft, hand or foot. .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64896.............. Nerve graft, hand or foot. .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64897.............. Nerve graft, arm or leg... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64898.............. Nerve graft, arm or leg... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64901.............. Nerve graft add-on........ .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64902.............. Nerve graft add-on........ .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64905.............. Nerve pedicle transfer.... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64907.............. Nerve pedicle transfer.... .................. T................. 0221 33.2707 $2,119.14 $463.62 $423.83
64910.............. Nerve repair w/allograft.. .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
64911.............. Neurorraphy w/vein .................. T................. 0220 18.0518 $1,149.79 ........... $229.96
autograft.
64999.............. Nervous system surgery.... .................. T................. 0204 2.3213 $147.85 $40.13 $29.57
65091.............. Revise eye................ .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
65093.............. Revise eye with implant... .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
65101.............. Removal of eye............ .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
65103.............. Remove eye/insert implant. .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
65105.............. Remove eye/attach implant. .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
65110.............. Removal of eye............ .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
[[Page 67066]]
65112.............. Remove eye/revise socket.. .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
65114.............. Remove eye/revise socket.. .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
65125.............. Revise ocular implant..... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
65130.............. Insert ocular implant..... .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
65135.............. Insert ocular implant..... .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
65140.............. Attach ocular implant..... .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
65150.............. Revise ocular implant..... .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
65155.............. Reinsert ocular implant... .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
65175.............. Removal of ocular implant. .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
65205.............. Remove foreign body from .................. S................. 0698 0.8696 $55.39 ........... $11.08
eye.
65210.............. Remove foreign body from .................. S................. 0698 0.8696 $55.39 ........... $11.08
eye.
65220.............. Remove foreign body from .................. S................. 0698 0.8696 $55.39 ........... $11.08
eye.
65222.............. Remove foreign body from .................. S................. 0698 0.8696 $55.39 ........... $11.08
eye.
65235.............. Remove foreign body from .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
eye.
65260.............. Remove foreign body from .................. T................. 0236 18.2350 $1,161.46 ........... $232.29
eye.
65265.............. Remove foreign body from .................. T................. 0237 27.8450 $1,773.56 ........... $354.71
eye.
65270.............. Repair of eye wound....... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
65272.............. Repair of eye wound....... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
65273.............. Repair of eye wound....... .................. C................. ........... ........... ........... ........... ...........
65275.............. Repair of eye wound....... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
65280.............. Repair of eye wound....... .................. T................. 0236 18.2350 $1,161.46 ........... $232.29
65285.............. Repair of eye wound....... .................. T................. 0672 37.2078 $2,369.91 ........... $473.98
65286.............. Repair of eye wound....... .................. T................. 0232 5.1169 $325.92 $81.65 $65.18
65290.............. Repair of eye socket wound .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
65400.............. Removal of eye lesion..... .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
65410.............. Biopsy of cornea.......... .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
65420.............. Removal of eye lesion..... .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
65426.............. Removal of eye lesion..... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
65430.............. Corneal smear............. .................. S................. 0698 0.8696 $55.39 ........... $11.08
65435.............. Curette/treat cornea...... .................. T................. 0239 7.2847 $463.99 ........... $92.80
65436.............. Curette/treat cornea...... .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
65450.............. Treatment of corneal .................. S................. 0231 2.1790 $138.79 ........... $27.76
lesion.
65600.............. Revision of cornea........ .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
65710.............. Corneal transplant........ .................. T................. 0244 37.4896 $2,387.86 $803.26 $477.57
65730.............. Corneal transplant........ .................. T................. 0244 37.4896 $2,387.86 $803.26 $477.57
65750.............. Corneal transplant........ .................. T................. 0244 37.4896 $2,387.86 $803.26 $477.57
65755.............. Corneal transplant........ .................. T................. 0244 37.4896 $2,387.86 $803.26 $477.57
65760.............. Revision of cornea........ .................. E................. ........... ........... ........... ........... ...........
65765.............. Revision of cornea........ .................. E................. ........... ........... ........... ........... ...........
65767.............. Corneal tissue transplant. .................. E................. ........... ........... ........... ........... ...........
65770.............. Revise cornea with implant .................. T................. 0293 84.8039 $5,401.50 $1,128.29 $1,080.30
65771.............. Radial keratotomy......... .................. E................. ........... ........... ........... ........... ...........
65772.............. Correction of astigmatism. .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
65775.............. Correction of astigmatism. .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
65780.............. Ocular reconst, transplant .................. T................. 0244 37.4896 $2,387.86 $803.26 $477.57
65781.............. Ocular reconst, transplant .................. T................. 0244 37.4896 $2,387.86 $803.26 $477.57
65782.............. Ocular reconst, transplant .................. T................. 0244 37.4896 $2,387.86 $803.26 $477.57
65800.............. Drainage of eye........... .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
65805.............. Drainage of eye........... .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
65810.............. Drainage of eye........... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
65815.............. Drainage of eye........... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
65820.............. Relieve inner eye pressure .................. T................. 0232 5.1169 $325.92 $81.65 $65.18
65850.............. Incision of eye........... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
65855.............. Laser surgery of eye...... .................. T................. 0247 5.2001 $331.22 $104.31 $66.24
65860.............. Incise inner eye adhesions .................. T................. 0247 5.2001 $331.22 $104.31 $66.24
65865.............. Incise inner eye adhesions .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
65870.............. Incise inner eye adhesions .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
65875.............. Incise inner eye adhesions .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
65880.............. Incise inner eye adhesions .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
65900.............. Remove eye lesion......... .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
65920.............. Remove implant of eye..... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
65930.............. Remove blood clot from eye .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66020.............. Injection treatment of eye .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
66030.............. Injection treatment of eye .................. T................. 0232 5.1169 $325.92 $81.65 $65.18
66130.............. Remove eye lesion......... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66150.............. Glaucoma surgery.......... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66155.............. Glaucoma surgery.......... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66160.............. Glaucoma surgery.......... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66165.............. Glaucoma surgery.......... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66170.............. Glaucoma surgery.......... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66172.............. Incision of eye........... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66180.............. Implant eye shunt......... .................. T................. 0673 39.7101 $2,529.30 $649.56 $505.86
66185.............. Revise eye shunt.......... .................. T................. 0673 39.7101 $2,529.30 $649.56 $505.86
66220.............. Repair eye lesion......... .................. T................. 0672 37.2078 $2,369.91 ........... $473.98
66225.............. Repair/graft eye lesion... .................. T................. 0673 39.7101 $2,529.30 $649.56 $505.86
66250.............. Follow-up surgery of eye.. .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
66500.............. Incision of iris.......... .................. T................. 0232 5.1169 $325.92 $81.65 $65.18
66505.............. Incision of iris.......... .................. T................. 0232 5.1169 $325.92 $81.65 $65.18
66600.............. Remove iris and lesion.... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66605.............. Removal of iris........... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
[[Page 67067]]
66625.............. Removal of iris........... .................. T................. 0232 5.1169 $325.92 $81.65 $65.18
66630.............. Removal of iris........... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66635.............. Removal of iris........... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66680.............. Repair iris & ciliary body .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66682.............. Repair iris & ciliary body .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66700.............. Destruction, ciliary body. .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
66710.............. Ciliary transsleral .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
therapy.
66711.............. Ciliary endoscopic .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
ablation.
66720.............. Destruction, ciliary body. .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
66740.............. Destruction, ciliary body. .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
66761.............. Revision of iris.......... .................. T................. 0247 5.2001 $331.22 $104.31 $66.24
66762.............. Revision of iris.......... .................. T................. 0247 5.2001 $331.22 $104.31 $66.24
66770.............. Removal of inner eye .................. T................. 0247 5.2001 $331.22 $104.31 $66.24
lesion.
66820.............. Incision, secondary .................. T................. 0232 5.1169 $325.92 $81.65 $65.18
cataract.
66821.............. After cataract laser .................. T................. 0247 5.2001 $331.22 $104.31 $66.24
surgery.
66825.............. Reposition intraocular .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
lens.
66830.............. Removal of lens lesion.... .................. T................. 0232 5.1169 $325.92 $81.65 $65.18
66840.............. Removal of lens material.. .................. T................. 0245 14.9171 $950.13 $217.05 $190.03
66850.............. Removal of lens material.. .................. T................. 0249 28.7035 $1,828.24 $524.67 $365.65
66852.............. Removal of lens material.. .................. T................. 0249 28.7035 $1,828.24 $524.67 $365.65
66920.............. Extraction of lens........ .................. T................. 0249 28.7035 $1,828.24 $524.67 $365.65
66930.............. Extraction of lens........ .................. T................. 0249 28.7035 $1,828.24 $524.67 $365.65
66940.............. Extraction of lens........ .................. T................. 0245 14.9171 $950.13 $217.05 $190.03
66982.............. Cataract surgery, complex. .................. T................. 0246 23.8649 $1,520.05 $495.96 $304.01
66983.............. Cataract surg w/iol, 1 .................. T................. 0246 23.8649 $1,520.05 $495.96 $304.01
stage.
66984.............. Cataract surg w/iol, 1 .................. T................. 0246 23.8649 $1,520.05 $495.96 $304.01
stage.
66985.............. Insert lens prosthesis.... .................. T................. 0246 23.8649 $1,520.05 $495.96 $304.01
66986.............. Exchange lens prosthesis.. .................. T................. 0246 23.8649 $1,520.05 $495.96 $304.01
66990.............. Ophthalmic endoscope add- .................. N................. ........... ........... ........... ........... ...........
on.
66999.............. Eye surgery procedure..... .................. T................. 0232 5.1169 $325.92 $81.65 $65.18
67005.............. Partial removal of eye .................. T................. 0237 27.8450 $1,773.56 ........... $354.71
fluid.
67010.............. Partial removal of eye .................. T................. 0237 27.8450 $1,773.56 ........... $354.71
fluid.
67015.............. Release of eye fluid...... .................. T................. 0237 27.8450 $1,773.56 ........... $354.71
67025.............. Replace eye fluid......... .................. T................. 0237 27.8450 $1,773.56 ........... $354.71
67027.............. Implant eye drug system... .................. T................. 0672 37.2078 $2,369.91 ........... $473.98
67028.............. Injection eye drug........ CH................ S................. 0231 2.1790 $138.79 ........... $27.76
67030.............. Incise inner eye strands.. .................. T................. 0236 18.2350 $1,161.46 ........... $232.29
67031.............. Laser surgery, eye strands .................. T................. 0247 5.2001 $331.22 $104.31 $66.24
67036.............. Removal of inner eye fluid .................. T................. 0672 37.2078 $2,369.91 ........... $473.98
67038.............. Strip retinal membrane.... CH................ D................. ........... ........... ........... ........... ...........
67039.............. Laser treatment of retina. .................. T................. 0672 37.2078 $2,369.91 ........... $473.98
67040.............. Laser treatment of retina. .................. T................. 0672 37.2078 $2,369.91 ........... $473.98
67041.............. Vit for macular pucker.... NI................ T................. 0672 37.2078 $2,369.91 ........... $473.98
67042.............. Vit for macular hole...... NI................ T................. 0672 37.2078 $2,369.91 ........... $473.98
67043.............. Vit for membrane dissect.. NI................ T................. 0672 37.2078 $2,369.91 ........... $473.98
67101.............. Repair detached retina.... .................. T................. 0236 18.2350 $1,161.46 ........... $232.29
67105.............. Repair detached retina.... CH................ T................. 0247 5.2001 $331.22 $104.31 $66.24
67107.............. Repair detached retina.... .................. T................. 0672 37.2078 $2,369.91 ........... $473.98
67108.............. Repair detached retina.... .................. T................. 0672 37.2078 $2,369.91 ........... $473.98
67110.............. Repair detached retina.... .................. T................. 0236 18.2350 $1,161.46 ........... $232.29
67112.............. Rerepair detached retina.. .................. T................. 0672 37.2078 $2,369.91 ........... $473.98
67113.............. Repair retinal detach, NI................ T................. 0672 37.2078 $2,369.91 ........... $473.98
cplx.
67115.............. Release encircling .................. T................. 0236 18.2350 $1,161.46 ........... $232.29
material.
67120.............. Remove eye implant .................. T................. 0236 18.2350 $1,161.46 ........... $232.29
material.
67121.............. Remove eye implant .................. T................. 0237 27.8450 $1,773.56 ........... $354.71
material.
67141.............. Treatment of retina....... .................. T................. 0235 4.1331 $263.25 $58.93 $52.65
67145.............. Treatment of retina....... CH................ T................. 0247 5.2001 $331.22 $104.31 $66.24
67208.............. Treatment of retinal .................. T................. 0236 18.2350 $1,161.46 ........... $232.29
lesion.
67210.............. Treatment of retinal CH................ T................. 0247 5.2001 $331.22 $104.31 $66.24
lesion.
67218.............. Treatment of retinal .................. T................. 0236 18.2350 $1,161.46 ........... $232.29
lesion.
67220.............. Treatment of choroid .................. T................. 0235 4.1331 $263.25 $58.93 $52.65
lesion.
67221.............. Ocular photodynamic ther.. .................. T................. 0235 4.1331 $263.25 $58.93 $52.65
67225.............. Eye photodynamic ther add- .................. T................. 0235 4.1331 $263.25 $58.93 $52.65
on.
67227.............. Treatment of retinal .................. T................. 0237 27.8450 $1,773.56 ........... $354.71
lesion.
67228.............. Treatment of retinal CH................ T................. 0247 5.2001 $331.22 $104.31 $66.24
lesion.
67229.............. Tr retinal les preterm inf NI................ T................. 0247 5.2001 $331.22 $104.31 $66.24
67250.............. Reinforce eye wall........ .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67255.............. Reinforce/graft eye wall.. .................. T................. 0237 27.8450 $1,773.56 ........... $354.71
67299.............. Eye surgery procedure..... .................. T................. 0235 4.1331 $263.25 $58.93 $52.65
67311.............. Revise eye muscle......... .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
67312.............. Revise two eye muscles.... .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
67314.............. Revise eye muscle......... .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
67316.............. Revise two eye muscles.... .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
67318.............. Revise eye muscle(s)...... .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
67320.............. Revise eye muscle(s) add- .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
on.
67331.............. Eye surgery follow-up add- .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
on.
67332.............. Rerevise eye muscles add- .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
on.
67334.............. Revise eye muscle w/suture .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
67335.............. Eye suture during surgery. .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
67340.............. Revise eye muscle add-on.. .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
[[Page 67068]]
67343.............. Release eye tissue........ .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
67345.............. Destroy nerve of eye .................. T................. 0238 2.9022 $184.85 ........... $36.97
muscle.
67346.............. Biopsy, eye muscle........ .................. T................. 0699 13.7453 $875.49 ........... $175.10
67399.............. Eye muscle surgery .................. T................. 0243 24.1291 $1,536.88 $430.35 $307.38
procedure.
67400.............. Explore/biopsy eye socket. .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
67405.............. Explore/drain eye socket.. .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
67412.............. Explore/treat eye socket.. .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
67413.............. Explore/treat eye socket.. .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
67414.............. Explr/decompress eye .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
socket.
67415.............. Aspiration, orbital .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
contents.
67420.............. Explore/treat eye socket.. .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
67430.............. Explore/treat eye socket.. .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
67440.............. Explore/drain eye socket.. .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
67445.............. Explr/decompress eye .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
socket.
67450.............. Explore/biopsy eye socket. .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
67500.............. Inject/treat eye socket... .................. S................. 0231 2.1790 $138.79 ........... $27.76
67505.............. Inject/treat eye socket... .................. T................. 0238 2.9022 $184.85 ........... $36.97
67515.............. Inject/treat eye socket... .................. T................. 0238 2.9022 $184.85 ........... $36.97
67550.............. Insert eye socket implant. .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
67560.............. Revise eye socket implant. .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
67570.............. Decompress optic nerve.... .................. T................. 0242 37.7243 $2,402.81 $597.36 $480.56
67599.............. Orbit surgery procedure... .................. T................. 0238 2.9022 $184.85 ........... $36.97
67700.............. Drainage of eyelid abscess .................. T................. 0238 2.9022 $184.85 ........... $36.97
67710.............. Incision of eyelid........ .................. T................. 0239 7.2847 $463.99 ........... $92.80
67715.............. Incision of eyelid fold... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67800.............. Remove eyelid lesion...... .................. T................. 0238 2.9022 $184.85 ........... $36.97
67801.............. Remove eyelid lesions..... .................. T................. 0239 7.2847 $463.99 ........... $92.80
67805.............. Remove eyelid lesions..... .................. T................. 0238 2.9022 $184.85 ........... $36.97
67808.............. Remove eyelid lesion(s)... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67810.............. Biopsy of eyelid.......... .................. T................. 0238 2.9022 $184.85 ........... $36.97
67820.............. Revise eyelashes.......... .................. S................. 0698 0.8696 $55.39 ........... $11.08
67825.............. Revise eyelashes.......... .................. T................. 0238 2.9022 $184.85 ........... $36.97
67830.............. Revise eyelashes.......... .................. T................. 0239 7.2847 $463.99 ........... $92.80
67835.............. Revise eyelashes.......... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67840.............. Remove eyelid lesion...... .................. T................. 0239 7.2847 $463.99 ........... $92.80
67850.............. Treat eyelid lesion....... .................. T................. 0239 7.2847 $463.99 ........... $92.80
67875.............. Closure of eyelid by .................. T................. 0239 7.2847 $463.99 ........... $92.80
suture.
67880.............. Revision of eyelid........ .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
67882.............. Revision of eyelid........ .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67900.............. Repair brow defect........ .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67901.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67902.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67903.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67904.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67906.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67908.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67909.............. Revise eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67911.............. Revise eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67912.............. Correction eyelid w/ .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
implant.
67914.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67915.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67916.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67917.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67921.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67922.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67923.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67924.............. Repair eyelid defect...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67930.............. Repair eyelid wound....... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67935.............. Repair eyelid wound....... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67938.............. Remove eyelid foreign body CH................ S................. 0231 2.1790 $138.79 ........... $27.76
67950.............. Revision of eyelid........ .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67961.............. Revision of eyelid........ .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67966.............. Revision of eyelid........ .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67971.............. Reconstruction of eyelid.. .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
67973.............. Reconstruction of eyelid.. .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
67974.............. Reconstruction of eyelid.. .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
67975.............. Reconstruction of eyelid.. .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
67999.............. Revision of eyelid........ .................. T................. 0238 2.9022 $184.85 ........... $36.97
68020.............. Incise/drain eyelid lining .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
68040.............. Treatment of eyelid .................. S................. 0698 0.8696 $55.39 ........... $11.08
lesions.
68100.............. Biopsy of eyelid lining... .................. T................. 0232 5.1169 $325.92 $81.65 $65.18
68110.............. Remove eyelid lining .................. T................. 0699 13.7453 $875.49 ........... $175.10
lesion.
68115.............. Remove eyelid lining .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
lesion.
68130.............. Remove eyelid lining .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
lesion.
68135.............. Remove eyelid lining .................. T................. 0239 7.2847 $463.99 ........... $92.80
lesion.
68200.............. Treat eyelid by injection. CH................ S................. 0698 0.8696 $55.39 ........... $11.08
68320.............. Revise/graft eyelid lining .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
68325.............. Revise/graft eyelid lining .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
68326.............. Revise/graft eyelid lining .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
68328.............. Revise/graft eyelid lining .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
[[Page 67069]]
68330.............. Revise eyelid lining...... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
68335.............. Revise/graft eyelid lining .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
68340.............. Separate eyelid adhesions. .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
68360.............. Revise eyelid lining...... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
68362.............. Revise eyelid lining...... .................. T................. 0234 23.1758 $1,476.16 $511.31 $295.23
68371.............. Harvest eye tissue, .................. T................. 0233 16.1710 $1,030.00 $266.33 $206.00
alograft.
68399.............. Eyelid lining surgery..... .................. T................. 0238 2.9022 $184.85 ........... $36.97
68400.............. Incise/drain tear gland... .................. T................. 0238 2.9022 $184.85 ........... $36.97
68420.............. Incise/drain tear sac..... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
68440.............. Incise tear duct opening.. .................. T................. 0238 2.9022 $184.85 ........... $36.97
68500.............. Removal of tear gland..... .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
68505.............. Partial removal, tear .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
gland.
68510.............. Biopsy of tear gland...... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
68520.............. Removal of tear sac....... .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
68525.............. Biopsy of tear sac........ .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
68530.............. Clearance of tear duct.... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
68540.............. Remove tear gland lesion.. .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
68550.............. Remove tear gland lesion.. .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
68700.............. Repair tear ducts......... .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
68705.............. Revise tear duct opening.. .................. T................. 0238 2.9022 $184.85 ........... $36.97
68720.............. Create tear sac drain..... .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
68745.............. Create tear duct drain.... .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
68750.............. Create tear duct drain.... .................. T................. 0241 24.3077 $1,548.25 $383.45 $309.65
68760.............. Close tear duct opening... .................. S................. 0231 2.1790 $138.79 ........... $27.76
68761.............. Close tear duct opening... .................. S................. 0231 2.1790 $138.79 ........... $27.76
68770.............. Close tear system fistula. .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
68801.............. Dilate tear duct opening.. .................. S................. 0698 0.8696 $55.39 ........... $11.08
68810.............. Probe nasolacrimal duct... .................. S................. 0231 2.1790 $138.79 ........... $27.76
68811.............. Probe nasolacrimal duct... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
68815.............. Probe nasolacrimal duct... .................. T................. 0240 18.7307 $1,193.03 $309.52 $238.61
68816.............. Probe nl duct w/balloon... NI................ T................. 0240 18.7307 $1,193.03 $309.52 $238.61
68840.............. Explore/irrigate tear CH................ S................. 0231 2.1790 $138.79 ........... $27.76
ducts.
68850.............. Injection for tear sac x- .................. N................. ........... ........... ........... ........... ...........
ray.
68899.............. Tear duct system surgery.. .................. T................. 0238 2.9022 $184.85 ........... $36.97
69000.............. Drain external ear lesion. .................. T................. 0006 1.4066 $89.59 ........... $17.92
69005.............. Drain external ear lesion. .................. T................. 0008 18.3197 $1,166.85 ........... $233.37
69020.............. Drain outer ear canal .................. T................. 0006 1.4066 $89.59 ........... $17.92
lesion.
69090.............. Pierce earlobes........... .................. E................. ........... ........... ........... ........... ...........
69100.............. Biopsy of external ear.... CH................ T................. 0251 2.5002 $159.25 ........... $31.85
69105.............. Biopsy of external ear .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
canal.
69110.............. Remove external ear, .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
partial.
69120.............. Removal of external ear... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
69140.............. Remove ear canal lesion(s) .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
69145.............. Remove ear canal lesion(s) .................. T................. 0021 16.1001 $1,025.48 $219.48 $205.10
69150.............. Extensive ear canal .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
surgery.
69155.............. Extensive ear/neck surgery .................. C................. ........... ........... ........... ........... ...........
69200.............. Clear outer ear canal..... .................. X................. 0340 0.6310 $40.19 ........... $8.04
69205.............. Clear outer ear canal..... .................. T................. 0022 21.1098 $1,344.57 $354.45 $268.91
69210.............. Remove impacted ear wax... .................. X................. 0340 0.6310 $40.19 ........... $8.04
69220.............. Clean out mastoid cavity.. CH................ T................. 0013 0.7930 $50.51 ........... $10.10
69222.............. Clean out mastoid cavity.. CH................ T................. 0253 16.3288 $1,040.05 $282.29 $208.01
69300.............. Revise external ear....... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
69310.............. Rebuild outer ear canal... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69320.............. Rebuild outer ear canal... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69399.............. Outer ear surgery .................. T................. 0251 2.5002 $159.25 ........... $31.85
procedure.
69400.............. Inflate middle ear canal.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
69401.............. Inflate middle ear canal.. .................. T................. 0251 2.5002 $159.25 ........... $31.85
69405.............. Catheterize middle ear .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
canal.
69420.............. Incision of eardrum....... .................. T................. 0251 2.5002 $159.25 ........... $31.85
69421.............. Incision of eardrum....... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
69424.............. Remove ventilating tube... CH................ T................. 0253 16.3288 $1,040.05 $282.29 $208.01
69433.............. Create eardrum opening.... .................. T................. 0252 7.4474 $474.35 $109.16 $94.87
69436.............. Create eardrum opening.... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
69440.............. Exploration of middle ear. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
69450.............. Eardrum revision.......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69501.............. Mastoidectomy............. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69502.............. Mastoidectomy............. .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
69505.............. Remove mastoid structures. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69511.............. Extensive mastoid surgery. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69530.............. Extensive mastoid surgery. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69535.............. Remove part of temporal .................. C................. ........... ........... ........... ........... ...........
bone.
69540.............. Remove ear lesion......... .................. T................. 0253 16.3288 $1,040.05 $282.29 $208.01
69550.............. Remove ear lesion......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69552.............. Remove ear lesion......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69554.............. Remove ear lesion......... .................. C................. ........... ........... ........... ........... ...........
69601.............. Mastoid surgery revision.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69602.............. Mastoid surgery revision.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69603.............. Mastoid surgery revision.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69604.............. Mastoid surgery revision.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69605.............. Mastoid surgery revision.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
[[Page 67070]]
69610.............. Repair of eardrum......... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
69620.............. Repair of eardrum......... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
69631.............. Repair eardrum structures. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69632.............. Rebuild eardrum structures .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69633.............. Rebuild eardrum structures .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69635.............. Repair eardrum structures. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69636.............. Rebuild eardrum structures .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69637.............. Rebuild eardrum structures .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69641.............. Revise middle ear & .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
mastoid.
69642.............. Revise middle ear & .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
mastoid.
69643.............. Revise middle ear & .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
mastoid.
69644.............. Revise middle ear & .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
mastoid.
69645.............. Revise middle ear & .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
mastoid.
69646.............. Revise middle ear & .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
mastoid.
69650.............. Release middle ear bone... .................. T................. 0254 23.9765 $1,527.16 $321.35 $305.43
69660.............. Revise middle ear bone.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69661.............. Revise middle ear bone.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69662.............. Revise middle ear bone.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69666.............. Repair middle ear .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
structures.
69667.............. Repair middle ear .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
structures.
69670.............. Remove mastoid air cells.. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69676.............. Remove middle ear nerve... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69700.............. Close mastoid fistula..... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69710.............. Implant/replace hearing .................. E................. ........... ........... ........... ........... ...........
aid.
69711.............. Remove/repair hearing aid. .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69714.............. Implant temple bone w/ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
stimul.
69715.............. Temple bne implnt w/ .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
stimulat.
69717.............. Temple bone implant .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
revision.
69718.............. Revise temple bone implant .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69720.............. Release facial nerve...... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69725.............. Release facial nerve...... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69740.............. Repair facial nerve....... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69745.............. Repair facial nerve....... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69799.............. Middle ear surgery .................. T................. 0251 2.5002 $159.25 ........... $31.85
procedure.
69801.............. Incise inner ear.......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69802.............. Incise inner ear.......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69805.............. Explore inner ear......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69806.............. Explore inner ear......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69820.............. Establish inner ear window .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69840.............. Revise inner ear window... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69905.............. Remove inner ear.......... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69910.............. Remove inner ear & mastoid .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69915.............. Incise inner ear nerve.... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69930.............. Implant cochlear device... .................. T................. 0259 393.2242 $25,046.02 $8,543.66 $5,009.20
69949.............. Inner ear surgery .................. T................. 0251 2.5002 $159.25 ........... $31.85
procedure.
69950.............. Incise inner ear nerve.... .................. C................. ........... ........... ........... ........... ...........
69955.............. Release facial nerve...... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69960.............. Release inner ear canal... .................. T................. 0256 39.8776 $2,539.96 ........... $507.99
69970.............. Remove inner ear lesion... CH................ T................. 0256 39.8776 $2,539.96 ........... $507.99
69979.............. Temporal bone surgery..... .................. T................. 0251 2.5002 $159.25 ........... $31.85
69990.............. Microsurgery add-on....... .................. N................. ........... ........... ........... ........... ...........
70010.............. Contrast x-ray of brain... CH................ Q................. 0274 7.5589 $481.46 ........... $96.29
70015.............. Contrast x-ray of brain... CH................ Q................. 0274 7.5589 $481.46 ........... $96.29
70030.............. X-ray eye for foreign body .................. X................. 0260 0.6954 $44.29 ........... $8.86
70100.............. X-ray exam of jaw......... .................. X................. 0260 0.6954 $44.29 ........... $8.86
7010F.............. Pt info into recall system NI................ M................. ........... ........... ........... ........... ...........
70110.............. X-ray exam of jaw......... .................. X................. 0260 0.6954 $44.29 ........... $8.86
70120.............. X-ray exam of mastoids.... .................. X................. 0260 0.6954 $44.29 ........... $8.86
70130.............. X-ray exam of mastoids.... .................. X................. 0260 0.6954 $44.29 ........... $8.86
70134.............. X-ray exam of middle ear.. .................. X................. 0261 1.1570 $73.69 ........... $14.74
70140.............. X-ray exam of facial bones .................. X................. 0260 0.6954 $44.29 ........... $8.86
70150.............. X-ray exam of facial bones .................. X................. 0260 0.6954 $44.29 ........... $8.86
70160.............. X-ray exam of nasal bones. .................. X................. 0260 0.6954 $44.29 ........... $8.86
70170.............. X-ray exam of tear duct... CH................ Q................. 0317 5.3623 $341.55 $77.89 $68.31
70190.............. X-ray exam of eye sockets. .................. X................. 0260 0.6954 $44.29 ........... $8.86
70200.............. X-ray exam of eye sockets. .................. X................. 0260 0.6954 $44.29 ........... $8.86
70210.............. X-ray exam of sinuses..... .................. X................. 0260 0.6954 $44.29 ........... $8.86
70220.............. X-ray exam of sinuses..... .................. X................. 0260 0.6954 $44.29 ........... $8.86
70240.............. X-ray exam, pituitary .................. X................. 0260 0.6954 $44.29 ........... $8.86
saddle.
70250.............. X-ray exam of skull....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
70260.............. X-ray exam of skull....... .................. X................. 0261 1.1570 $73.69 ........... $14.74
70300.............. X-ray exam of teeth....... .................. X................. 0262 0.5749 $36.62 ........... $7.32
70310.............. X-ray exam of teeth....... .................. X................. 0262 0.5749 $36.62 ........... $7.32
70320.............. Full mouth x-ray of teeth. .................. X................. 0262 0.5749 $36.62 ........... $7.32
70328.............. X-ray exam of jaw joint... .................. X................. 0260 0.6954 $44.29 ........... $8.86
70330.............. X-ray exam of jaw joints.. .................. X................. 0260 0.6954 $44.29 ........... $8.86
70332.............. X-ray exam of jaw joint... CH................ Q................. 0275 4.0031 $254.97 $69.09 $50.99
70336.............. Magnetic image, jaw joint. .................. S................. 0335 4.8830 $311.02 $111.92 $62.20
70350.............. X-ray head for orthodontia .................. X................. 0260 0.6954 $44.29 ........... $8.86
70355.............. Panoramic x-ray of jaws... .................. X................. 0260 0.6954 $44.29 ........... $8.86
[[Page 67071]]
70360.............. X-ray exam of neck........ .................. X................. 0260 0.6954 $44.29 ........... $8.86
70370.............. Throat x-ray & fluoroscopy .................. X................. 0272 1.3271 $84.53 $31.64 $16.91
70371.............. Speech evaluation, complex .................. X................. 0272 1.3271 $84.53 $31.64 $16.91
70373.............. Contrast x-ray of larynx.. CH................ Q................. 0263 2.6838 $170.94 ........... $34.19
70380.............. X-ray exam of salivary .................. X................. 0260 0.6954 $44.29 ........... $8.86
gland.
70390.............. X-ray exam of salivary CH................ Q................. 0263 2.6838 $170.94 ........... $34.19
duct.
70450.............. Ct head/brain w/o dye..... .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
70460.............. Ct head/brain w/dye....... .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
70470.............. Ct head/brain w/o & w/dye. .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
70480.............. Ct orbit/ear/fossa w/o dye .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
70481.............. Ct orbit/ear/fossa w/dye.. .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
70482.............. Ct orbit/ear/fossa w/o&w/ .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
dye.
70486.............. Ct maxillofacial w/o dye.. .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
70487.............. Ct maxillofacial w/dye.... .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
70488.............. Ct maxillofacial w/o & w/ .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
dye.
70490.............. Ct soft tissue neck w/o .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
dye.
70491.............. Ct soft tissue neck w/dye. .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
70492.............. Ct sft tsue nck w/o & w/ .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
dye.
70496.............. Ct angiography, head...... .................. S................. 0662 5.1641 $328.92 $118.88 $65.78
70498.............. Ct angiography, neck...... .................. S................. 0662 5.1641 $328.92 $118.88 $65.78
70540.............. Mri orbit/face/neck w/o .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
dye.
70542.............. Mri orbit/face/neck w/dye. .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
70543.............. Mri orbt/fac/nck w/o & w/ .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
dye.
70544.............. Mr angiography head w/o .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
dye.
70545.............. Mr angiography head w/dye. .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
70546.............. Mr angiograph head w/o&w/ .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
dye.
70547.............. Mr angiography neck w/o .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
dye.
70548.............. Mr angiography neck w/dye. .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
70549.............. Mr angiograph neck w/o&w/ .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
dye.
70551.............. Mri brain w/o dye......... .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
70552.............. Mri brain w/dye........... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
70553.............. Mri brain w/o & w/dye..... .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
70554.............. Fmri brain by tech........ .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
70555.............. Fmri brain by phys/psych.. .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
70557.............. Mri brain w/o dye......... .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
70558.............. Mri brain w/dye........... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
70559.............. Mri brain w/o & w/dye..... .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
71010.............. Chest x-ray............... .................. X................. 0260 0.6954 $44.29 ........... $8.86
71015.............. Chest x-ray............... .................. X................. 0260 0.6954 $44.29 ........... $8.86
71020.............. Chest x-ray............... .................. X................. 0260 0.6954 $44.29 ........... $8.86
71021.............. Chest x-ray............... .................. X................. 0260 0.6954 $44.29 ........... $8.86
71022.............. Chest x-ray............... .................. X................. 0260 0.6954 $44.29 ........... $8.86
71023.............. Chest x-ray and .................. X................. 0272 1.3271 $84.53 $31.64 $16.91
fluoroscopy.
71030.............. Chest x-ray............... .................. X................. 0260 0.6954 $44.29 ........... $8.86
71034.............. Chest x-ray and .................. X................. 0272 1.3271 $84.53 $31.64 $16.91
fluoroscopy.
71035.............. Chest x-ray............... .................. X................. 0260 0.6954 $44.29 ........... $8.86
71040.............. Contrast x-ray of bronchi. CH................ Q................. 0263 2.6838 $170.94 ........... $34.19
71060.............. Contrast x-ray of bronchi. CH................ Q................. 0317 5.3623 $341.55 $77.89 $68.31
71090.............. X-ray & pacemaker CH................ N................. ........... ........... ........... ........... ...........
insertion.
71100.............. X-ray exam of ribs........ .................. X................. 0260 0.6954 $44.29 ........... $8.86
71101.............. X-ray exam of ribs/chest.. .................. X................. 0260 0.6954 $44.29 ........... $8.86
71110.............. X-ray exam of ribs........ .................. X................. 0260 0.6954 $44.29 ........... $8.86
71111.............. X-ray exam of ribs/chest.. .................. X................. 0261 1.1570 $73.69 ........... $14.74
71120.............. X-ray exam of breastbone.. .................. X................. 0260 0.6954 $44.29 ........... $8.86
71130.............. X-ray exam of breastbone.. .................. X................. 0260 0.6954 $44.29 ........... $8.86
71250.............. Ct thorax w/o dye......... .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
71260.............. Ct thorax w/dye........... .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
71270.............. Ct thorax w/o & w/dye..... .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
71275.............. Ct angiography, chest..... .................. S................. 0662 5.1641 $328.92 $118.88 $65.78
71550.............. Mri chest w/o dye......... .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
71551.............. Mri chest w/dye........... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
71552.............. Mri chest w/o & w/dye..... .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
71555.............. Mri angio chest w or w/o .................. B................. ........... ........... ........... ........... ...........
dye.
72010.............. X-ray exam of spine....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
72020.............. X-ray exam of spine....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
72040.............. X-ray exam of neck spine.. .................. X................. 0260 0.6954 $44.29 ........... $8.86
72050.............. X-ray exam of neck spine.. .................. X................. 0261 1.1570 $73.69 ........... $14.74
72052.............. X-ray exam of neck spine.. .................. X................. 0261 1.1570 $73.69 ........... $14.74
72069.............. X-ray exam of trunk spine. .................. X................. 0260 0.6954 $44.29 ........... $8.86
72070.............. X-ray exam of thoracic .................. X................. 0260 0.6954 $44.29 ........... $8.86
spine.
72072.............. X-ray exam of thoracic .................. X................. 0260 0.6954 $44.29 ........... $8.86
spine.
72074.............. X-ray exam of thoracic .................. X................. 0260 0.6954 $44.29 ........... $8.86
spine.
72080.............. X-ray exam of trunk spine. .................. X................. 0260 0.6954 $44.29 ........... $8.86
72090.............. X-ray exam of trunk spine. .................. X................. 0261 1.1570 $73.69 ........... $14.74
72100.............. X-ray exam of lower spine. .................. X................. 0260 0.6954 $44.29 ........... $8.86
72110.............. X-ray exam of lower spine. .................. X................. 0261 1.1570 $73.69 ........... $14.74
72114.............. X-ray exam of lower spine. .................. X................. 0261 1.1570 $73.69 ........... $14.74
72120.............. X-ray exam of lower spine. .................. X................. 0261 1.1570 $73.69 ........... $14.74
72125.............. Ct neck spine w/o dye..... .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
72126.............. Ct neck spine w/dye....... .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
[[Page 67072]]
72127.............. Ct neck spine w/o & w/dye. .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
72128.............. Ct chest spine w/o dye.... .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
72129.............. Ct chest spine w/dye...... .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
72130.............. Ct chest spine w/o & w/dye .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
72131.............. Ct lumbar spine w/o dye... .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
72132.............. Ct lumbar spine w/dye..... .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
72133.............. Ct lumbar spine w/o & w/ .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
dye.
72141.............. Mri neck spine w/o dye.... .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
72142.............. Mri neck spine w/dye...... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
72146.............. Mri chest spine w/o dye... .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
72147.............. Mri chest spine w/dye..... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
72148.............. Mri lumbar spine w/o dye.. .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
72149.............. Mri lumbar spine w/dye.... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
72156.............. Mri neck spine w/o & w/dye .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
72157.............. Mri chest spine w/o & w/ .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
dye.
72158.............. Mri lumbar spine w/o & w/ .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
dye.
72159.............. Mr angio spine w/o&w/dye.. .................. E................. ........... ........... ........... ........... ...........
72170.............. X-ray exam of pelvis...... .................. X................. 0260 0.6954 $44.29 ........... $8.86
72190.............. X-ray exam of pelvis...... .................. X................. 0260 0.6954 $44.29 ........... $8.86
72191.............. Ct angiograph pelv w/o&w/ .................. S................. 0662 5.1641 $328.92 $118.88 $65.78
dye.
72192.............. Ct pelvis w/o dye......... .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
72193.............. Ct pelvis w/dye........... .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
72194.............. Ct pelvis w/o & w/dye..... .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
72195.............. Mri pelvis w/o dye........ .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
72196.............. Mri pelvis w/dye.......... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
72197.............. Mri pelvis w/o & w/dye.... .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
72198.............. Mr angio pelvis w/o & w/ .................. B................. ........... ........... ........... ........... ...........
dye.
72200.............. X-ray exam sacroiliac .................. X................. 0260 0.6954 $44.29 ........... $8.86
joints.
72202.............. X-ray exam sacroiliac .................. X................. 0260 0.6954 $44.29 ........... $8.86
joints.
72220.............. X-ray exam of tailbone.... .................. X................. 0260 0.6954 $44.29 ........... $8.86
72240.............. Contrast x-ray of neck CH................ Q................. 0274 7.5589 $481.46 ........... $96.29
spine.
72255.............. Contrast x-ray, thorax CH................ Q................. 0274 7.5589 $481.46 ........... $96.29
spine.
72265.............. Contrast x-ray, lower CH................ Q................. 0274 7.5589 $481.46 ........... $96.29
spine.
72270.............. Contrast x-ray, spine..... CH................ Q................. 0274 7.5589 $481.46 ........... $96.29
72275.............. Epidurography............. CH................ N................. ........... ........... ........... ........... ...........
72285.............. X-ray c/t spine disk...... CH................ Q................. 0388 20.1823 $1,285.49 $289.72 $257.10
72291.............. Perq vertebroplasty, fluor CH................ N................. ........... ........... ........... ........... ...........
72292.............. Perq vertebroplasty, ct... CH................ N................. ........... ........... ........... ........... ...........
72295.............. X-ray of lower spine disk. CH................ Q................. 0388 20.1823 $1,285.49 $289.72 $257.10
73000.............. X-ray exam of collar bone. .................. X................. 0260 0.6954 $44.29 ........... $8.86
73010.............. X-ray exam of shoulder .................. X................. 0260 0.6954 $44.29 ........... $8.86
blade.
73020.............. X-ray exam of shoulder.... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73030.............. X-ray exam of shoulder.... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73040.............. Contrast x-ray of shoulder CH................ Q................. 0275 4.0031 $254.97 $69.09 $50.99
73050.............. X-ray exam of shoulders... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73060.............. X-ray exam of humerus..... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73070.............. X-ray exam of elbow....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73080.............. X-ray exam of elbow....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73085.............. Contrast x-ray of elbow... CH................ Q................. 0275 4.0031 $254.97 $69.09 $50.99
73090.............. X-ray exam of forearm..... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73092.............. X-ray exam of arm, infant. .................. X................. 0260 0.6954 $44.29 ........... $8.86
73100.............. X-ray exam of wrist....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73110.............. X-ray exam of wrist....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73115.............. Contrast x-ray of wrist... CH................ Q................. 0275 4.0031 $254.97 $69.09 $50.99
73120.............. X-ray exam of hand........ .................. X................. 0260 0.6954 $44.29 ........... $8.86
73130.............. X-ray exam of hand........ .................. X................. 0260 0.6954 $44.29 ........... $8.86
73140.............. X-ray exam of finger(s)... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73200.............. Ct upper extremity w/o dye .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
73201.............. Ct upper extremity w/dye.. .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
73202.............. Ct uppr extremity w/o&w/ .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
dye.
73206.............. Ct angio upr extrm w/o&w/ .................. S................. 0662 5.1641 $328.92 $118.88 $65.78
dye.
73218.............. Mri upper extremity w/o .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
dye.
73219.............. Mri upper extremity w/dye. .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
73220.............. Mri uppr extremity w/o&w/ .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
dye.
73221.............. Mri joint upr extrem w/o .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
dye.
73222.............. Mri joint upr extrem w/dye .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
73223.............. Mri joint upr extr w/o&w/ .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
dye.
73225.............. Mr angio upr extr w/o&w/ .................. E................. ........... ........... ........... ........... ...........
dye.
73500.............. X-ray exam of hip......... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73510.............. X-ray exam of hip......... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73520.............. X-ray exam of hips........ .................. X................. 0261 1.1570 $73.69 ........... $14.74
73525.............. Contrast x-ray of hip..... CH................ Q................. 0275 4.0031 $254.97 $69.09 $50.99
73530.............. X-ray exam of hip......... CH................ N................. ........... ........... ........... ........... ...........
73540.............. X-ray exam of pelvis & .................. X................. 0260 0.6954 $44.29 ........... $8.86
hips.
73542.............. X-ray exam, sacroiliac CH................ Q................. 0275 4.0031 $254.97 $69.09 $50.99
joint.
73550.............. X-ray exam of thigh....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73560.............. X-ray exam of knee, 1 or 2 .................. X................. 0260 0.6954 $44.29 ........... $8.86
73562.............. X-ray exam of knee, 3..... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73564.............. X-ray exam, knee, 4 or .................. X................. 0260 0.6954 $44.29 ........... $8.86
more.
73565.............. X-ray exam of knees....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
[[Page 67073]]
73580.............. Contrast x-ray of knee CH................ Q................. 0275 4.0031 $254.97 $69.09 $50.99
joint.
73590.............. X-ray exam of lower leg... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73592.............. X-ray exam of leg, infant. .................. X................. 0260 0.6954 $44.29 ........... $8.86
73600.............. X-ray exam of ankle....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73610.............. X-ray exam of ankle....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73615.............. Contrast x-ray of ankle... CH................ Q................. 0275 4.0031 $254.97 $69.09 $50.99
73620.............. X-ray exam of foot........ .................. X................. 0260 0.6954 $44.29 ........... $8.86
73630.............. X-ray exam of foot........ .................. X................. 0260 0.6954 $44.29 ........... $8.86
73650.............. X-ray exam of heel........ .................. X................. 0260 0.6954 $44.29 ........... $8.86
73660.............. X-ray exam of toe(s)...... .................. X................. 0260 0.6954 $44.29 ........... $8.86
73700.............. Ct lower extremity w/o dye .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
73701.............. Ct lower extremity w/dye.. .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
73702.............. Ct lwr extremity w/o&w/dye .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
73706.............. Ct angio lwr extr w/o&w/ .................. S................. 0662 5.1641 $328.92 $118.88 $65.78
dye.
73718.............. Mri lower extremity w/o .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
dye.
73719.............. Mri lower extremity w/dye. .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
73720.............. Mri lwr extremity w/o&w/ .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
dye.
73721.............. Mri jnt of lwr extre w/o .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
dye.
73722.............. Mri joint of lwr extr w/ .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
dye.
73723.............. Mri joint lwr extr w/o&w/ .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
dye.
73725.............. Mr ang lwr ext w or w/o .................. B................. ........... ........... ........... ........... ...........
dye.
74000.............. X-ray exam of abdomen..... .................. X................. 0260 0.6954 $44.29 ........... $8.86
74010.............. X-ray exam of abdomen..... .................. X................. 0260 0.6954 $44.29 ........... $8.86
74020.............. X-ray exam of abdomen..... .................. X................. 0260 0.6954 $44.29 ........... $8.86
74022.............. X-ray exam series, abdomen .................. X................. 0261 1.1570 $73.69 ........... $14.74
74150.............. Ct abdomen w/o dye........ .................. S................. 0332 3.0109 $191.78 $75.24 $38.36
74160.............. Ct abdomen w/dye.......... .................. S................. 0283 4.3564 $277.48 $100.37 $55.50
74170.............. Ct abdomen w/o & w/dye.... .................. S................. 0333 5.1125 $325.64 $119.01 $65.13
74175.............. Ct angio abdom w/o & w/dye .................. S................. 0662 5.1641 $328.92 $118.88 $65.78
74181.............. Mri abdomen w/o dye....... .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
74182.............. Mri abdomen w/dye......... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
74183.............. Mri abdomen w/o & w/dye... .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
74185.............. Mri angio, abdom w orw/o .................. B................. ........... ........... ........... ........... ...........
dye.
74190.............. X-ray exam of peritoneum.. CH................ Q................. 0317 5.3623 $341.55 $77.89 $68.31
74210.............. Contrst x-ray exam of .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
throat.
74220.............. Contrast x-ray, esophagus. .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
74230.............. Cine/vid x-ray, throat/ .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
esoph.
74235.............. Remove esophagus CH................ N................. ........... ........... ........... ........... ...........
obstruction.
74240.............. X-ray exam, upper gi tract .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
74241.............. X-ray exam, upper gi tract .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
74245.............. X-ray exam, upper gi tract .................. S................. 0277 2.2222 $141.54 $54.52 $28.31
74246.............. Contrst x-ray uppr gi .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
tract.
74247.............. Contrst x-ray uppr gi .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
tract.
74249.............. Contrst x-ray uppr gi .................. S................. 0277 2.2222 $141.54 $54.52 $28.31
tract.
74250.............. X-ray exam of small bowel. .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
74251.............. X-ray exam of small bowel. .................. S................. 0277 2.2222 $141.54 $54.52 $28.31
74260.............. X-ray exam of small bowel. .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
74270.............. Contrast x-ray exam of .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
colon.
74280.............. Contrast x-ray exam of .................. S................. 0277 2.2222 $141.54 $54.52 $28.31
colon.
74283.............. Contrast x-ray exam of .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
colon.
74290.............. Contrast x-ray, .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
gallbladder.
74291.............. Contrast x-rays, .................. S................. 0276 1.3834 $88.11 $34.97 $17.62
gallbladder.
74300.............. X-ray bile ducts/pancreas. CH................ N................. ........... ........... ........... ........... ...........
74301.............. X-rays at surgery add-on.. CH................ N................. ........... ........... ........... ........... ...........
74305.............. X-ray bile ducts/pancreas. CH................ N................. ........... ........... ........... ........... ...........
74320.............. Contrast x-ray of bile CH................ Q................. 0317 5.3623 $341.55 $77.89 $68.31
ducts.
74327.............. X-ray bile stone removal.. CH................ N................. ........... ........... ........... ........... ...........
74328.............. X-ray bile duct endoscopy. .................. N................. ........... ........... ........... ........... ...........
74329.............. X-ray for pancreas .................. N................. ........... ........... ........... ........... ...........
endoscopy.
74330.............. X-ray bile/panc endoscopy. .................. N................. ........... ........... ........... ........... ...........
74340.............. X-ray guide for GI tube... CH................ N................. ........... ........... ........... ........... ...........
74350.............. X-ray guide, stomach tube. CH................ D................. ........... ........... ........... ........... ...........
74355.............. X-ray guide, intestinal CH................ N................. ........... ........... ........... ........... ...........
tube.
74360.............. X-ray guide, GI dilation.. CH................ N................. ........... ........... ........... ........... ...........
74363.............. X-ray, bile duct dilation. CH................ N................. ........... ........... ........... ........... ...........
74400.............. Contrst x-ray, urinary .................. S................. 0278 2.6121 $166.38 $59.40 $33.28
tract.
74410.............. Contrst x-ray, urinary .................. S................. 0278 2.6121 $166.38 $59.40 $33.28
tract.
74415.............. Contrst x-ray, urinary .................. S................. 0278 2.6121 $166.38 $59.40 $33.28
tract.
74420.............. Contrst x-ray, urinary .................. S................. 0278 2.6121 $166.38 $59.40 $33.28
tract.
74425.............. Contrst x-ray, urinary CH................ Q................. 0278 2.6121 $166.38 $59.40 $33.28
tract.
74430.............. Contrast x-ray, bladder... CH................ Q................. 0278 2.6121 $166.38 $59.40 $33.28
74440.............. X-ray, male genital tract. CH................ Q................. 0278 2.6121 $166.38 $59.40 $33.28
74445.............. X-ray exam of penis....... CH................ Q................. 0278 2.6121 $166.38 $59.40 $33.28
74450.............. X-ray, urethra/bladder.... CH................ Q................. 0278 2.6121 $166.38 $59.40 $33.28
74455.............. X-ray, urethra/bladder.... CH................ Q................. 0278 2.6121 $166.38 $59.40 $33.28
74470.............. X-ray exam of kidney CH................ Q................. 0263 2.6838 $170.94 ........... $34.19
lesion.
74475.............. X-ray control, cath insert CH................ Q................. 0317 5.3623 $341.55 $77.89 $68.31
74480.............. X-ray control, cath insert CH................ Q................. 0317 5.3623 $341.55 $77.89 $68.31
74485.............. X-ray guide, GU dilation.. CH................ Q................. 0317 5.3623 $341.55 $77.89 $68.31
74710.............. X-ray measurement of .................. X................. 0261 1.1570 $73.69 ........... $14.74
pelvis.
[[Page 67074]]
74740.............. X-ray, female genital CH................ Q................. 0263 2.6838 $170.94 ........... $34.19
tract.
74742.............. X-ray, fallopian tube..... CH................ N................. ........... ........... ........... ........... ...........
74775.............. X-ray exam of perineum.... .................. S................. 0278 2.6121 $166.38 $59.40 $33.28
75552.............. Heart mri for morph w/o CH................ D................. ........... ........... ........... ........... ...........
dye.
75553.............. Heart mri for morph w/dye. CH................ D................. ........... ........... ........... ........... ...........
75554.............. Cardiac MRI/function...... CH................ D................. ........... ........... ........... ........... ...........
75555.............. Cardiac MRI/limited study. CH................ D................. ........... ........... ........... ........... ...........
75556.............. Cardiac MRI/flow mapping.. CH................ D................. ........... ........... ........... ........... ...........
75557.............. Cardiac mri for morph..... NI................ S................. 0336 5.3933 $343.52 $137.40 $68.70
75558.............. Cardiac mri flow/velocity. NI................ E................. ........... ........... ........... ........... ...........
75559.............. Cardiac mri w/stress img.. NI................ S................. 0336 5.3933 $343.52 $137.40 $68.70
75560.............. Cardiac mri flow/vel/ NI................ E................. ........... ........... ........... ........... ...........
stress.
75561.............. Cardiac mri for morph w/ NI................ S................. 0337 8.2463 $525.24 $199.53 $105.05
dye.
75562.............. Card mri flow/vel w/dye... NI................ E................. ........... ........... ........... ........... ...........
75563.............. Card mri w/stress img & NI................ S................. 0337 8.2463 $525.24 $199.53 $105.05
dye.
75564.............. Ht mri w/flo/vel/strs & NI................ E................. ........... ........... ........... ........... ...........
dye.
75600.............. Contrast x-ray exam of CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
aorta.
75605.............. Contrast x-ray exam of CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
aorta.
75625.............. Contrast x-ray exam of CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
aorta.
75630.............. X-ray aorta, leg arteries. CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75635.............. Ct angio abdominal CH................ Q................. 0662 5.1641 $328.92 $118.88 $65.78
arteries.
75650.............. Artery x-rays, head & neck CH................ Q................. 0280 44.7114 $2,847.85 ........... $569.57
75658.............. Artery x-rays, arm........ CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75660.............. Artery x-rays, head & neck CH................ Q................. 0280 44.7114 $2,847.85 ........... $569.57
75662.............. Artery x-rays, head & neck CH................ Q................. 0280 44.7114 $2,847.85 ........... $569.57
75665.............. Artery x-rays, head & neck CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75671.............. Artery x-rays, head & neck CH................ Q................. 0280 44.7114 $2,847.85 ........... $569.57
75676.............. Artery x-rays, neck....... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75680.............. Artery x-rays, neck....... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75685.............. Artery x-rays, spine...... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75705.............. Artery x-rays, spine...... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75710.............. Artery x-rays, arm/leg.... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75716.............. Artery x-rays, arms/legs.. CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75722.............. Artery x-rays, kidney..... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75724.............. Artery x-rays, kidneys.... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75726.............. Artery x-rays, abdomen.... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75731.............. Artery x-rays, adrenal CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
gland.
75733.............. Artery x-rays, adrenals... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75736.............. Artery x-rays, pelvis..... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75741.............. Artery x-rays, lung....... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75743.............. Artery x-rays, lungs...... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75746.............. Artery x-rays, lung....... CH................ Q................. 0668 9.3506 $595.58 ........... $119.12
75756.............. Artery x-rays, chest...... CH................ Q................. 0668 9.3506 $595.58 ........... $119.12
75774.............. Artery x-ray, each vessel. CH................ N................. ........... ........... ........... ........... ...........
75790.............. Visualize A-V shunt....... CH................ Q................. 0668 9.3506 $595.58 ........... $119.12
75801.............. Lymph vessel x-ray, arm/ CH................ Q................. 0317 5.3623 $341.55 $77.89 $68.31
leg.
75803.............. Lymph vessel x-ray,arms/ CH................ Q................. 0317 5.3623 $341.55 $77.89 $68.31
legs.
75805.............. Lymph vessel x-ray, trunk. CH................ Q................. 0317 5.3623 $341.55 $77.89 $68.31
75807.............. Lymph vessel x-ray, trunk. CH................ Q................. 0317 5.3623 $341.55 $77.89 $68.31
75809.............. Nonvascular shunt, x-ray.. CH................ Q................. 0263 2.6838 $170.94 ........... $34.19
75810.............. Vein x-ray, spleen/liver.. CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75820.............. Vein x-ray, arm/leg....... CH................ Q................. 0668 9.3506 $595.58 ........... $119.12
75822.............. Vein x-ray, arms/legs..... CH................ Q................. 0668 9.3506 $595.58 ........... $119.12
75825.............. Vein x-ray, trunk......... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75827.............. Vein x-ray, chest......... CH................ Q................. 0668 9.3506 $595.58 ........... $119.12
75831.............. Vein x-ray, kidney........ CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75833.............. Vein x-ray, kidneys....... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75840.............. Vein x-ray, adrenal gland. CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75842.............. Vein x-ray, adrenal glands CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75860.............. Vein x-ray, neck.......... CH................ Q................. 0668 9.3506 $595.58 ........... $119.12
75870.............. Vein x-ray, skull......... CH................ Q................. 0668 9.3506 $595.58 ........... $119.12
75872.............. Vein x-ray, skull......... CH................ Q................. 0668 9.3506 $595.58 ........... $119.12
75880.............. Vein x-ray, eye socket.... CH................ Q................. 0668 9.3506 $595.58 ........... $119.12
75885.............. Vein x-ray, liver......... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75887.............. Vein x-ray, liver......... CH................ Q................. 0668 9.3506 $595.58 ........... $119.12
75889.............. Vein x-ray, liver......... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75891.............. Vein x-ray, liver......... CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
75893.............. Venous sampling by CH................ Q................. 0279 28.8788 $1,839.41 ........... $367.88
catheter.
75894.............. X-rays, transcath therapy. CH................ N................. ........... ........... ........... ........... ...........
75896.............. X-rays, transcath therapy. CH................ N................. ........... ........... ........... ........... ...........
75898.............. Follow-up angiography..... CH................ Q................. 0263 2.6838 $170.94 ........... $34.19
75900.............. Intravascular cath .................. C................. ........... ........... ........... ........... ...........
exchange.
75901.............. Remove cva device obstruct CH................ N................. ........... ........... ........... ........... ...........
75902.............. Remove cva lumen obstruct. CH................ N................. ........... ........... ........... ........... ...........
75940.............. X-ray placement, vein CH................ N................. ........... ........... ........... ........... ...........
filter.
75945.............. Intravascular us.......... CH................ Q................. 0267 2.3792 $151.54 $60.50 $30.31
75946.............. Intravascular us add-on... CH................ N................. ........... ........... ........... ........... ...........
75952.............. Endovasc repair abdom .................. C................. ........... ........... ........... ........... ...........
aorta.
75953.............. Abdom aneurysm endovas rpr .................. C................. ........... ........... ........... ........... ...........
75954.............. Iliac aneurysm endovas rpr .................. C................. ........... ........... ........... ........... ...........
[[Page 67075]]
75956.............. Xray, endovasc thor ao .................. C................. ........... ........... ........... ........... ...........
repr.
75957.............. Xray, endovasc thor ao .................. C................. ........... ........... ........... ........... ...........
repr.
75958.............. Xray, place prox ext thor .................. C................. ........... ........... ........... ........... ...........
ao.
75959.............. Xray, place dist ext thor .................. C................. ........... ........... ........... ........... ...........
ao.
75960.............. Transcath iv stent rs&i... CH................ N................. ........... ........... ........... ........... ...........
75961.............. Retrieval, broken catheter CH................ N................. ........... ........... ........... ........... ...........
75962.............. Repair arterial blockage.. CH................ Q................. 0083 45.3845 $2,890.72 ........... $578.14
75964.............. Repair artery blockage, CH................ N................. ........... ........... ........... ........... ...........
each.
75966.............. Repair arterial blockage.. CH................ Q................. 0083 45.3845 $2,890.72 ........... $578.14
75968.............. Repair artery blockage, CH................ N................. ........... ........... ........... ........... ...........
each.
75970.............. Vascular biopsy........... CH................ N................. ........... ........... ........... ........... ...........
75978.............. Repair venous blockage.... CH................ Q................. 0083 45.3845 $2,890.72 ........... $578.14
75980.............. Contrast xray exam bile CH................ N................. ........... ........... ........... ........... ...........
duct.
75982.............. Contrast xray exam bile CH................ N................. ........... ........... ........... ........... ...........
duct.
75984.............. Xray control catheter CH................ N................. ........... ........... ........... ........... ...........
change.
75989.............. Abscess drainage under x- .................. N................. ........... ........... ........... ........... ...........
ray.
75992.............. Atherectomy, x-ray exam... CH................ N................. ........... ........... ........... ........... ...........
75993.............. Atherectomy, x-ray exam... CH................ N................. ........... ........... ........... ........... ...........
75994.............. Atherectomy, x-ray exam... CH................ N................. ........... ........... ........... ........... ...........
75995.............. Atherectomy, x-ray exam... CH................ N................. ........... ........... ........... ........... ...........
75996.............. Atherectomy, x-ray exam... CH................ N................. ........... ........... ........... ........... ...........
76000.............. Fluoroscope examination... CH................ Q................. 0272 1.3271 $84.53 $31.64 $16.91
76001.............. Fluoroscope exam, .................. N................. ........... ........... ........... ........... ...........
extensive.
76010.............. X-ray, nose to rectum..... .................. X................. 0260 0.6954 $44.29 ........... $8.86
76080.............. X-ray exam of fistula..... CH................ Q................. 0263 2.6838 $170.94 ........... $34.19
76098.............. X-ray exam, breast .................. X................. 0260 0.6954 $44.29 ........... $8.86
specimen.
76100.............. X-ray exam of body section .................. X................. 0261 1.1570 $73.69 ........... $14.74
76101.............. Complex body section x-ray .................. X................. 0263 2.6838 $170.94 ........... $34.19
76102.............. Complex body section x- CH................ X................. 0263 2.6838 $170.94 ........... $34.19
rays.
76120.............. Cine/video x-rays......... .................. X................. 0272 1.3271 $84.53 $31.64 $16.91
76125.............. Cine/video x-rays add-on.. CH................ N................. ........... ........... ........... ........... ...........
76140.............. X-ray consultation........ .................. E................. ........... ........... ........... ........... ...........
76150.............. X-ray exam, dry process... .................. X................. 0260 0.6954 $44.29 ........... $8.86
76350.............. Special x-ray contrast .................. N................. ........... ........... ........... ........... ...........
study.
76376.............. 3d render w/o postprocess. CH................ N................. ........... ........... ........... ........... ...........
76377.............. 3d rendering w/postprocess CH................ N................. ........... ........... ........... ........... ...........
76380.............. CAT scan follow-up study.. .................. S................. 0282 1.5839 $100.88 $37.81 $20.18
76390.............. Mr spectroscopy........... .................. E................. ........... ........... ........... ........... ...........
76496.............. Fluoroscopic procedure.... .................. X................. 0272 1.3271 $84.53 $31.64 $16.91
76497.............. Ct procedure.............. .................. S................. 0282 1.5839 $100.88 $37.81 $20.18
76498.............. Mri procedure............. .................. S................. 0335 4.8830 $311.02 $111.92 $62.20
76499.............. Radiographic procedure.... .................. X................. 0260 0.6954 $44.29 ........... $8.86
76506.............. Echo exam of head......... .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
76510.............. Ophth us, b & quant a..... CH................ T................. 0232 5.1169 $325.92 $81.65 $65.18
76511.............. Ophth us, quant a only.... .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76512.............. Ophth us, b w/non-quant a. .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76513.............. Echo exam of eye, water .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
bath.
76514.............. Echo exam of eye, CH................ S................. 0230 0.5903 $37.60 ........... $7.52
thickness.
76516.............. Echo exam of eye.......... .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
76519.............. Echo exam of eye.......... .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76529.............. Echo exam of eye.......... .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
76536.............. Us exam of head and neck.. .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76604.............. Us exam, chest............ .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
76645.............. Us exam, breast(s)........ .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
76700.............. Us exam, abdom, complete.. .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76705.............. Echo exam of abdomen...... .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76770.............. Us exam abdo back wall, .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
comp.
76775.............. Us exam abdo back wall, .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
lim.
76776.............. Us exam k transpl w/ .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
doppler.
76800.............. Us exam, spinal canal..... .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76801.............. Ob us < 14 wks, single .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
fetus.
76802.............. Ob us < 14 wks, add'l .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
fetus.
76805.............. Ob us >/= 14 wks, sngl .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
fetus.
76810.............. Ob us >/= 14 wks, addl .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
fetus.
76811.............. Ob us, detailed, sngl .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
fetus.
76812.............. Ob us, detailed, addl .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
fetus.
76813.............. Ob us nuchal meas, 1 gest. .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76814.............. Ob us nuchal meas, add-on. .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
76815.............. Ob us, limited, fetus(s).. .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
76816.............. Ob us, follow-up, per .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
fetus.
76817.............. Transvaginal us, obstetric .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
76818.............. Fetal biophys profile w/ .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
nst.
76819.............. Fetal biophys profil w/o .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
nst.
76820.............. Umbilical artery echo..... .................. S................. 0096 1.4689 $93.56 $37.42 $18.71
76821.............. Middle cerebral artery .................. S................. 0096 1.4689 $93.56 $37.42 $18.71
echo.
76825.............. Echo exam of fetal heart.. CH................ S................. 0266 1.5094 $96.14 $37.80 $19.23
76826.............. Echo exam of fetal heart.. CH................ S................. 0265 0.9570 $60.96 $22.35 $12.19
76827.............. Echo exam of fetal heart.. CH................ S................. 0265 0.9570 $60.96 $22.35 $12.19
76828.............. Echo exam of fetal heart.. CH................ S................. 0265 0.9570 $60.96 $22.35 $12.19
76830.............. Transvaginal us, non-ob... .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
[[Page 67076]]
76831.............. Echo exam, uterus......... .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
76856.............. Us exam, pelvic, complete. .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76857.............. Us exam, pelvic, limited.. .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
76870.............. Us exam, scrotum.......... .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76872.............. Us, transrectal........... .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76873.............. Echograp trans r, pros .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
study.
76880.............. Us exam, extremity........ .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
76885.............. Us exam infant hips, .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
dynamic.
76886.............. Us exam infant hips, .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
static.
76930.............. Echo guide, cardiocentesis CH................ N................. ........... ........... ........... ........... ...........
76932.............. Echo guide for heart CH................ N................. ........... ........... ........... ........... ...........
biopsy.
76936.............. Echo guide for artery CH................ N................. ........... ........... ........... ........... ...........
repair.
76937.............. Us guide, vascular access. .................. N................. ........... ........... ........... ........... ...........
76940.............. Us guide, tissue ablation. CH................ N................. ........... ........... ........... ........... ...........
76941.............. Echo guide for transfusion CH................ N................. ........... ........... ........... ........... ...........
76942.............. Echo guide for biopsy..... CH................ N................. ........... ........... ........... ........... ...........
76945.............. Echo guide, villus CH................ N................. ........... ........... ........... ........... ...........
sampling.
76946.............. Echo guide for CH................ N................. ........... ........... ........... ........... ...........
amniocentesis.
76948.............. Echo guide, ova aspiration CH................ N................. ........... ........... ........... ........... ...........
76950.............. Echo guidance radiotherapy CH................ N................. ........... ........... ........... ........... ...........
76965.............. Echo guidance radiotherapy CH................ N................. ........... ........... ........... ........... ...........
76970.............. Ultrasound exam follow-up. .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
76975.............. GI endoscopic ultrasound.. CH................ Q................. 0267 2.3792 $151.54 $60.50 $30.31
76977.............. Us bone density measure... .................. X................. 0340 0.6310 $40.19 ........... $8.04
76998.............. Us guide, intraop......... CH................ N................. ........... ........... ........... ........... ...........
76999.............. Echo examination procedure .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
77001.............. Fluoroguide for vein .................. N................. ........... ........... ........... ........... ...........
device.
77002.............. Needle localization by .................. N................. ........... ........... ........... ........... ...........
xray.
77003.............. Fluoroguide for spine .................. N................. ........... ........... ........... ........... ...........
inject.
77011.............. Ct scan for localization.. CH................ N................. ........... ........... ........... ........... ...........
77012.............. Ct scan for needle biopsy. CH................ N................. ........... ........... ........... ........... ...........
77013.............. Ct guide for tissue CH................ N................. ........... ........... ........... ........... ...........
ablation.
77014.............. Ct scan for therapy guide. CH................ N................. ........... ........... ........... ........... ...........
77021.............. Mr guidance for needle CH................ N................. ........... ........... ........... ........... ...........
place.
77022.............. Mri for tissue ablation... CH................ N................. ........... ........... ........... ........... ...........
77031.............. Stereotact guide for brst CH................ N................. ........... ........... ........... ........... ...........
bx.
77032.............. Guidance for needle, CH................ N................. ........... ........... ........... ........... ...........
breast.
77051.............. Computer dx mammogram add- .................. A................. ........... ........... ........... ........... ...........
on.
77052.............. Comp screen mammogram add- .................. A................. ........... ........... ........... ........... ...........
on.
77053.............. X-ray of mammary duct..... CH................ Q................. 0263 2.6838 $170.94 ........... $34.19
77054.............. X-ray of mammary ducts.... CH................ Q................. 0263 2.6838 $170.94 ........... $34.19
77055.............. Mammogram, one breast..... .................. A................. ........... ........... ........... ........... ...........
77056.............. Mammogram, both breasts... .................. A................. ........... ........... ........... ........... ...........
77057.............. Mammogram, screening...... .................. A................. ........... ........... ........... ........... ...........
77058.............. Mri, one breast........... .................. B................. ........... ........... ........... ........... ...........
77059.............. Mri, both breasts......... .................. B................. ........... ........... ........... ........... ...........
77071.............. X-ray stress view......... .................. X................. 0260 0.6954 $44.29 ........... $8.86
77072.............. X-rays for bone age....... .................. X................. 0260 0.6954 $44.29 ........... $8.86
77073.............. X-rays, bone length .................. X................. 0260 0.6954 $44.29 ........... $8.86
studies.
77074.............. X-rays, bone survey, .................. X................. 0261 1.1570 $73.69 ........... $14.74
limited.
77075.............. X-rays, bone survey .................. X................. 0261 1.1570 $73.69 ........... $14.74
complete.
77076.............. X-rays, bone survey, .................. X................. 0260 0.6954 $44.29 ........... $8.86
infant.
77077.............. Joint survey, single view. .................. X................. 0260 0.6954 $44.29 ........... $8.86
77078.............. Ct bone density, axial.... .................. S................. 0288 1.1384 $72.51 $28.90 $14.50
77079.............. Ct bone density, .................. S................. 0282 1.5839 $100.88 $37.81 $20.18
peripheral.
77080.............. Dxa bone density, axial... .................. S................. 0288 1.1384 $72.51 $28.90 $14.50
77081.............. Dxa bone density/ .................. S................. 0665 0.5087 $32.40 $12.95 $6.48
peripheral.
77082.............. Dxa bone density, vert fx. .................. X................. 0260 0.6954 $44.29 ........... $8.86
77083.............. Radiographic .................. X................. 0261 1.1570 $73.69 ........... $14.74
absorptiometry.
77084.............. Magnetic image, bone .................. S................. 0335 4.8830 $311.02 $111.92 $62.20
marrow.
77261.............. Radiation therapy planning .................. B................. ........... ........... ........... ........... ...........
77262.............. Radiation therapy planning .................. B................. ........... ........... ........... ........... ...........
77263.............. Radiation therapy planning .................. B................. ........... ........... ........... ........... ...........
77280.............. Set radiation therapy .................. X................. 0304 1.5576 $99.21 $38.68 $19.84
field.
77285.............. Set radiation therapy .................. X................. 0305 3.9276 $250.16 $91.38 $50.03
field.
77290.............. Set radiation therapy .................. X................. 0305 3.9276 $250.16 $91.38 $50.03
field.
77295.............. Set radiation therapy .................. X................. 0310 13.5621 $863.82 $325.27 $172.76
field.
77299.............. Radiation therapy planning .................. X................. 0304 1.5576 $99.21 $38.68 $19.84
77300.............. Radiation therapy dose .................. X................. 0304 1.5576 $99.21 $38.68 $19.84
plan.
77301.............. Radiotherapy dose plan, .................. X................. 0310 13.5621 $863.82 $325.27 $172.76
imrt.
77305.............. Teletx isodose plan simple .................. X................. 0304 1.5576 $99.21 $38.68 $19.84
77310.............. Teletx isodose plan .................. X................. 0305 3.9276 $250.16 $91.38 $50.03
intermed.
77315.............. Teletx isodose plan .................. X................. 0305 3.9276 $250.16 $91.38 $50.03
complex.
77321.............. Special teletx port plan.. .................. X................. 0305 3.9276 $250.16 $91.38 $50.03
77326.............. Brachytx isodose calc simp .................. X................. 0304 1.5576 $99.21 $38.68 $19.84
77327.............. Brachytx isodose calc .................. X................. 0305 3.9276 $250.16 $91.38 $50.03
interm.
77328.............. Brachytx isodose plan .................. X................. 0305 3.9276 $250.16 $91.38 $50.03
compl.
77331.............. Special radiation .................. X................. 0304 1.5576 $99.21 $38.68 $19.84
dosimetry.
77332.............. Radiation treatment aid(s) .................. X................. 0303 2.8878 $183.94 $66.95 $36.79
77333.............. Radiation treatment aid(s) .................. X................. 0303 2.8878 $183.94 $66.95 $36.79
[[Page 67077]]
77334.............. Radiation treatment aid(s) .................. X................. 0303 2.8878 $183.94 $66.95 $36.79
77336.............. Radiation physics consult. .................. X................. 0304 1.5576 $99.21 $38.68 $19.84
77370.............. Radiation physics consult. .................. X................. 0304 1.5576 $99.21 $38.68 $19.84
77371.............. Srs, multisource.......... .................. S................. 0127 126.4653 $8,055.08 ........... $1,611.02
77372.............. Srs, linear based......... .................. B................. ........... ........... ........... ........... ...........
77373.............. Sbrt delivery............. .................. B................. ........... ........... ........... ........... ...........
77399.............. External radiation .................. X................. 0304 1.5576 $99.21 $38.68 $19.84
dosimetry.
77401.............. Radiation treatment .................. S................. 0300 1.4229 $90.63 ........... $18.13
delivery.
77402.............. Radiation treatment .................. S................. 0300 1.4229 $90.63 ........... $18.13
delivery.
77403.............. Radiation treatment .................. S................. 0300 1.4229 $90.63 ........... $18.13
delivery.
77404.............. Radiation treatment .................. S................. 0300 1.4229 $90.63 ........... $18.13
delivery.
77406.............. Radiation treatment .................. S................. 0300 1.4229 $90.63 ........... $18.13
delivery.
77407.............. Radiation treatment .................. S................. 0300 1.4229 $90.63 ........... $18.13
delivery.
77408.............. Radiation treatment .................. S................. 0300 1.4229 $90.63 ........... $18.13
delivery.
77409.............. Radiation treatment .................. S................. 0300 1.4229 $90.63 ........... $18.13
delivery.
77411.............. Radiation treatment .................. S................. 0301 2.2167 $141.19 ........... $28.24
delivery.
77412.............. Radiation treatment .................. S................. 0301 2.2167 $141.19 ........... $28.24
delivery.
77413.............. Radiation treatment .................. S................. 0301 2.2167 $141.19 ........... $28.24
delivery.
77414.............. Radiation treatment .................. S................. 0301 2.2167 $141.19 ........... $28.24
delivery.
77416.............. Radiation treatment .................. S................. 0301 2.2167 $141.19 ........... $28.24
delivery.
77417.............. Radiology port film(s).... CH................ N................. ........... ........... ........... ........... ...........
77418.............. Radiation tx delivery, .................. S................. 0412 5.4582 $347.65 ........... $69.53
imrt.
77421.............. Stereoscopic x-ray CH................ N................. ........... ........... ........... ........... ...........
guidance.
77422.............. Neutron beam tx, simple... .................. S................. 0301 2.2167 $141.19 ........... $28.24
77423.............. Neutron beam tx, complex.. .................. S................. 0301 2.2167 $141.19 ........... $28.24
77427.............. Radiation tx management, .................. B................. ........... ........... ........... ........... ...........
x5.
77431.............. Radiation therapy .................. B................. ........... ........... ........... ........... ...........
management.
77432.............. Stereotactic radiation .................. B................. ........... ........... ........... ........... ...........
trmt.
77435.............. Sbrt management........... .................. N................. ........... ........... ........... ........... ...........
77470.............. Special radiation .................. S................. 0299 5.7996 $369.40 ........... $73.88
treatment.
77499.............. Radiation therapy .................. B................. ........... ........... ........... ........... ...........
management.
77520.............. Proton trmt, simple w/o .................. S................. 0664 12.8205 $816.59 ........... $163.32
comp.
77522.............. Proton trmt, simple w/comp .................. S................. 0664 12.8205 $816.59 ........... $163.32
77523.............. Proton trmt, intermediate. .................. S................. 0667 15.3404 $977.09 ........... $195.42
77525.............. Proton treatment, complex. .................. S................. 0667 15.3404 $977.09 ........... $195.42
77600.............. Hyperthermia treatment.... CH................ S................. 0299 5.7996 $369.40 ........... $73.88
77605.............. Hyperthermia treatment.... CH................ S................. 0299 5.7996 $369.40 ........... $73.88
77610.............. Hyperthermia treatment.... CH................ S................. 0299 5.7996 $369.40 ........... $73.88
77615.............. Hyperthermia treatment.... CH................ S................. 0299 5.7996 $369.40 ........... $73.88
77620.............. Hyperthermia treatment.... CH................ S................. 0299 5.7996 $369.40 ........... $73.88
77750.............. Infuse radioactive .................. S................. 0301 2.2167 $141.19 ........... $28.24
materials.
77761.............. Apply intrcav radiat .................. S................. 0312 8.5140 $542.29 ........... $108.46
simple.
77762.............. Apply intrcav radiat .................. S................. 0312 8.5140 $542.29 ........... $108.46
interm.
77763.............. Apply intrcav radiat compl .................. S................. 0312 8.5140 $542.29 ........... $108.46
77776.............. Apply interstit radiat .................. S................. 0312 8.5140 $542.29 ........... $108.46
simpl.
77777.............. Apply interstit radiat .................. S................. 0312 8.5140 $542.29 ........... $108.46
inter.
77778.............. Apply interstit radiat CH................ Q................. 0651 18.1228 $1,154.31 ........... $230.86
compl.
77781.............. High intensity .................. S................. 0313 11.6779 $743.81 ........... $148.76
brachytherapy.
77782.............. High intensity .................. S................. 0313 11.6779 $743.81 ........... $148.76
brachytherapy.
77783.............. High intensity .................. S................. 0313 11.6779 $743.81 ........... $148.76
brachytherapy.
77784.............. High intensity .................. S................. 0313 11.6779 $743.81 ........... $148.76
brachytherapy.
77789.............. Apply surface radiation... .................. S................. 0300 1.4229 $90.63 ........... $18.13
77790.............. Radiation handling........ .................. N................. ........... ........... ........... ........... ...........
77799.............. Radium/radioisotope .................. S................. 0312 8.5140 $542.29 ........... $108.46
therapy.
78000.............. Thyroid, single uptake.... .................. S................. 0389 1.8190 $115.86 $33.81 $23.17
78001.............. Thyroid, multiple uptakes. .................. S................. 0389 1.8190 $115.86 $33.81 $23.17
78003.............. Thyroid suppress/stimul... .................. S................. 0392 2.9022 $184.85 $49.31 $36.97
78006.............. Thyroid imaging with CH................ S................. 0391 3.4513 $219.83 $66.18 $43.97
uptake.
78007.............. Thyroid image, mult .................. S................. 0391 3.4513 $219.83 $66.18 $43.97
uptakes.
78010.............. Thyroid imaging........... .................. S................. 0390 2.0471 $130.39 $52.15 $26.08
78011.............. Thyroid imaging with flow. .................. S................. 0390 2.0471 $130.39 $52.15 $26.08
78015.............. Thyroid met imaging....... .................. S................. 0406 5.0681 $322.81 $98.18 $64.56
78016.............. Thyroid met imaging/ .................. S................. 0406 5.0681 $322.81 $98.18 $64.56
studies.
78018.............. Thyroid met imaging, body. .................. S................. 0406 5.0681 $322.81 $98.18 $64.56
78020.............. Thyroid met uptake........ CH................ N................. ........... ........... ........... ........... ...........
78070.............. Parathyroid nuclear .................. S................. 0391 3.4513 $219.83 $66.18 $43.97
imaging.
78075.............. Adrenal nuclear imaging... CH................ S................. 0408 15.4033 $981.10 ........... $196.22
78099.............. Endocrine nuclear .................. S................. 0390 2.0471 $130.39 $52.15 $26.08
procedure.
78102.............. Bone marrow imaging, ltd.. .................. S................. 0400 3.9293 $250.27 $93.22 $50.05
78103.............. Bone marrow imaging, mult. .................. S................. 0400 3.9293 $250.27 $93.22 $50.05
78104.............. Bone marrow imaging, body. .................. S................. 0400 3.9293 $250.27 $93.22 $50.05
78110.............. Plasma volume, single..... .................. S................. 0393 5.6921 $362.55 $82.04 $72.51
78111.............. Plasma volume, multiple... .................. S................. 0393 5.6921 $362.55 $82.04 $72.51
78120.............. Red cell mass, single..... .................. S................. 0393 5.6921 $362.55 $82.04 $72.51
78121.............. Red cell mass, multiple... .................. S................. 0393 5.6921 $362.55 $82.04 $72.51
78122.............. Blood volume.............. .................. S................. 0393 5.6921 $362.55 $82.04 $72.51
78130.............. Red cell survival study... .................. S................. 0393 5.6921 $362.55 $82.04 $72.51
78135.............. Red cell survival kinetics .................. S................. 0393 5.6921 $362.55 $82.04 $72.51
78140.............. Red cell sequestration.... .................. S................. 0393 5.6921 $362.55 $82.04 $72.51
78185.............. Spleen imaging............ .................. S................. 0400 3.9293 $250.27 $93.22 $50.05
[[Page 67078]]
78190.............. Platelet survival, .................. S................. 0392 2.9022 $184.85 $49.31 $36.97
kinetics.
78191.............. Platelet survival......... .................. S................. 0392 2.9022 $184.85 $49.31 $36.97
78195.............. Lymph system imaging...... .................. S................. 0400 3.9293 $250.27 $93.22 $50.05
78199.............. Blood/lymph nuclear exam.. .................. S................. 0400 3.9293 $250.27 $93.22 $50.05
78201.............. Liver imaging............. .................. S................. 0394 4.4603 $284.09 $102.61 $56.82
78202.............. Liver imaging with flow... .................. S................. 0394 4.4603 $284.09 $102.61 $56.82
78205.............. Liver imaging (3D)........ .................. S................. 0394 4.4603 $284.09 $102.61 $56.82
78206.............. Liver image (3d) with flow .................. S................. 0394 4.4603 $284.09 $102.61 $56.82
78215.............. Liver and spleen imaging.. .................. S................. 0394 4.4603 $284.09 $102.61 $56.82
78216.............. Liver & spleen image/flow. .................. S................. 0394 4.4603 $284.09 $102.61 $56.82
78220.............. Liver function study...... .................. S................. 0394 4.4603 $284.09 $102.61 $56.82
78223.............. Hepatobiliary imaging..... .................. S................. 0394 4.4603 $284.09 $102.61 $56.82
78230.............. Salivary gland imaging.... .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
78231.............. Serial salivary imaging... .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
78232.............. Salivary gland function .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
exam.
78258.............. Esophageal motility study. .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
78261.............. Gastric mucosa imaging.... .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
78262.............. Gastroesophageal reflux .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
exam.
78264.............. Gastric emptying study.... .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
78267.............. Breath tst attain/anal c- .................. A................. ........... ........... ........... ........... ...........
14.
78268.............. Breath test analysis, c-14 .................. A................. ........... ........... ........... ........... ...........
78270.............. Vit B-12 absorption exam.. .................. S................. 0392 2.9022 $184.85 $49.31 $36.97
78271.............. Vit b-12 absrp exam, int .................. S................. 0392 2.9022 $184.85 $49.31 $36.97
fac.
78272.............. Vit B-12 absorp, combined. .................. S................. 0392 2.9022 $184.85 $49.31 $36.97
78278.............. Acute GI blood loss .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
imaging.
78282.............. GI protein loss exam...... .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
78290.............. Meckel's divert exam...... .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
78291.............. Leveen/shunt patency exam. .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
78299.............. GI nuclear procedure...... .................. S................. 0395 3.7911 $241.47 $89.73 $48.29
78300.............. Bone imaging, limited area .................. S................. 0396 3.8039 $242.29 $95.02 $48.46
78305.............. Bone imaging, multiple .................. S................. 0396 3.8039 $242.29 $95.02 $48.46
areas.
78306.............. Bone imaging, whole body.. .................. S................. 0396 3.8039 $242.29 $95.02 $48.46
78315.............. Bone imaging, 3 phase..... .................. S................. 0396 3.8039 $242.29 $95.02 $48.46
78320.............. Bone imaging (3D)......... .................. S................. 0396 3.8039 $242.29 $95.02 $48.46
78350.............. Bone mineral, single .................. E................. ........... ........... ........... ........... ...........
photon.
78351.............. Bone mineral, dual photon. .................. E................. ........... ........... ........... ........... ...........
78399.............. Musculoskeletal nuclear .................. S................. 0396 3.8039 $242.29 $95.02 $48.46
exam.
78414.............. Non-imaging heart function .................. S................. 0398 4.8620 $309.68 $100.06 $61.94
78428.............. Cardiac shunt imaging..... .................. S................. 0398 4.8620 $309.68 $100.06 $61.94
78445.............. Vascular flow imaging..... .................. S................. 0397 3.1433 $200.21 $49.58 $40.04
78456.............. Acute venous thrombus .................. S................. 0397 3.1433 $200.21 $49.58 $40.04
image.
78457.............. Venous thrombosis imaging. .................. S................. 0397 3.1433 $200.21 $49.58 $40.04
78458.............. Ven thrombosis images, .................. S................. 0397 3.1433 $200.21 $49.58 $40.04
bilat.
78459.............. Heart muscle imaging (PET) .................. S................. 0307 21.9955 $1,400.98 $292.49 $280.20
78460.............. Heart muscle blood, single CH................ S................. 0377 11.8512 $754.85 $158.84 $150.97
78461.............. Heart muscle blood, CH................ S................. 0377 11.8512 $754.85 $158.84 $150.97
multiple.
78464.............. Heart image (3d), single.. CH................ S................. 0377 11.8512 $754.85 $158.84 $150.97
78465.............. Heart image (3d), multiple .................. S................. 0377 11.8512 $754.85 $158.84 $150.97
78466.............. Heart infarct image....... .................. S................. 0398 4.8620 $309.68 $100.06 $61.94
78468.............. Heart infarct image (ef).. .................. S................. 0398 4.8620 $309.68 $100.06 $61.94
78469.............. Heart infarct image (3D).. .................. S................. 0398 4.8620 $309.68 $100.06 $61.94
78472.............. Gated heart, planar, .................. S................. 0398 4.8620 $309.68 $100.06 $61.94
single.
78473.............. Gated heart, multiple..... CH................ S................. 0398 4.8620 $309.68 $100.06 $61.94
78478.............. Heart wall motion add-on.. CH................ N................. ........... ........... ........... ........... ...........
78480.............. Heart function add-on..... CH................ N................. ........... ........... ........... ........... ...........
78481.............. Heart first pass, single.. .................. S................. 0398 4.8620 $309.68 $100.06 $61.94
78483.............. Heart first pass, multiple CH................ S................. 0398 4.8620 $309.68 $100.06 $61.94
78491.............. Heart image (pet), single. .................. S................. 0307 21.9955 $1,400.98 $292.49 $280.20
78492.............. Heart image (pet), .................. S................. 0307 21.9955 $1,400.98 $292.49 $280.20
multiple.
78494.............. Heart image, spect........ .................. S................. 0398 4.8620 $309.68 $100.06 $61.94
78496.............. Heart first pass add-on... CH................ N................. ........... ........... ........... ........... ...........
78499.............. Cardiovascular nuclear .................. S................. 0398 4.8620 $309.68 $100.06 $61.94
exam.
78580.............. Lung perfusion imaging.... .................. S................. 0401 3.3954 $216.27 $78.19 $43.25
78584.............. Lung V/Q image single .................. S................. 0378 4.9509 $315.34 $125.33 $63.07
breath.
78585.............. Lung V/Q imaging.......... .................. S................. 0378 4.9509 $315.34 $125.33 $63.07
78586.............. Aerosol lung image, single .................. S................. 0401 3.3954 $216.27 $78.19 $43.25
78587.............. Aerosol lung image, .................. S................. 0401 3.3954 $216.27 $78.19 $43.25
multiple.
78588.............. Perfusion lung image...... .................. S................. 0378 4.9509 $315.34 $125.33 $63.07
78591.............. Vent image, 1 breath, 1 .................. S................. 0401 3.3954 $216.27 $78.19 $43.25
proj.
78593.............. Vent image, 1 proj, gas... .................. S................. 0401 3.3954 $216.27 $78.19 $43.25
78594.............. Vent image, mult proj, gas .................. S................. 0401 3.3954 $216.27 $78.19 $43.25
78596.............. Lung differential function .................. S................. 0378 4.9509 $315.34 $125.33 $63.07
78599.............. Respiratory nuclear exam.. .................. S................. 0401 3.3954 $216.27 $78.19 $43.25
78600.............. Brain image < 4 views..... CH................ S................. 0403 3.2295 $205.70 $79.87 $41.14
78601.............. Brain image w/flow < 4 CH................ S................. 0403 3.2295 $205.70 $79.87 $41.14
views.
78605.............. Brain image 4+ views...... CH................ S................. 0403 3.2295 $205.70 $79.87 $41.14
78606.............. Brain image w/flow 4 + .................. S................. 0402 8.8235 $562.00 $114.12 $112.40
views.
78607.............. Brain imaging (3D)........ .................. S................. 0402 8.8235 $562.00 $114.12 $112.40
78608.............. Brain imaging (PET)....... .................. S................. 0308 16.6001 $1,057.33 ........... $211.47
78609.............. Brain imaging (PET)....... .................. E................. ........... ........... ........... ........... ...........
[[Page 67079]]
78610.............. Brain flow imaging only... .................. S................. 0402 8.8235 $562.00 $114.12 $112.40
78615.............. Cerebral vascular flow CH................ D................. ........... ........... ........... ........... ...........
image.
78630.............. Cerebrospinal fluid scan.. CH................ S................. 0402 8.8235 $562.00 $114.12 $112.40
78635.............. CSF ventriculography...... CH................ S................. 0402 8.8235 $562.00 $114.12 $112.40
78645.............. CSF shunt evaluation...... .................. S................. 0403 3.2295 $205.70 $79.87 $41.14
78647.............. Cerebrospinal fluid scan.. CH................ S................. 0402 8.8235 $562.00 $114.12 $112.40
78650.............. CSF leakage imaging....... CH................ S................. 0402 8.8235 $562.00 $114.12 $112.40
78660.............. Nuclear exam of tear flow. .................. S................. 0403 3.2295 $205.70 $79.87 $41.14
78699.............. Nervous system nuclear CH................ S................. 0403 3.2295 $205.70 $79.87 $41.14
exam.
78700.............. Kidney imaging, morphol... .................. S................. 0404 5.0824 $323.72 $84.11 $64.74
78701.............. Kidney imaging with flow.. .................. S................. 0404 5.0824 $323.72 $84.11 $64.74
78707.............. K flow/funct image w/o .................. S................. 0404 5.0824 $323.72 $84.11 $64.74
drug.
78708.............. K flow/funct image w/drug. CH................ S................. 0404 5.0824 $323.72 $84.11 $64.74
78709.............. K flow/funct image, CH................ S................. 0404 5.0824 $323.72 $84.11 $64.74
multiple.
78710.............. Kidney imaging (3D)....... .................. S................. 0404 5.0824 $323.72 $84.11 $64.74
78725.............. Kidney function study..... CH................ S................. 0392 2.9022 $184.85 $49.31 $36.97
78730.............. Urinary bladder retention. CH................ S................. 0389 1.8190 $115.86 $33.81 $23.17
78740.............. Ureteral reflux study..... .................. S................. 0404 5.0824 $323.72 $84.11 $64.74
78761.............. Testicular imaging w/flow. .................. S................. 0404 5.0824 $323.72 $84.11 $64.74
78799.............. Genitourinary nuclear exam .................. S................. 0404 5.0824 $323.72 $84.11 $64.74
78800.............. Tumor imaging, limited .................. S................. 0406 5.0681 $322.81 $98.18 $64.56
area.
78801.............. Tumor imaging, mult areas. .................. S................. 0406 5.0681 $322.81 $98.18 $64.56
78802.............. Tumor imaging, whole body. CH................ S................. 0414 8.4176 $536.15 $214.44 $107.23
78803.............. Tumor imaging (3D)........ CH................ S................. 0408 15.4033 $981.10 ........... $196.22
78804.............. Tumor imaging, whole body. .................. S................. 0408 15.4033 $981.10 ........... $196.22
78805.............. Abscess imaging, ltd area. CH................ S................. 0414 8.4176 $536.15 $214.44 $107.23
78806.............. Abscess imaging, whole CH................ S................. 0414 8.4176 $536.15 $214.44 $107.23
body.
78807.............. Nuclear localization/ CH................ S................. 0414 8.4176 $536.15 $214.44 $107.23
abscess.
78811.............. Pet image, ltd area....... .................. S................. 0308 16.6001 $1,057.33 ........... $211.47
78812.............. Pet image, skull-thigh.... .................. S................. 0308 16.6001 $1,057.33 ........... $211.47
78813.............. Pet image, full body...... .................. S................. 0308 16.6001 $1,057.33 ........... $211.47
78814.............. Pet image w/ct, lmtd...... CH................ S................. 0308 16.6001 $1,057.33 ........... $211.47
78815.............. Pet image w/ct, skull- CH................ S................. 0308 16.6001 $1,057.33 ........... $211.47
thigh.
78816.............. Pet image w/ct, full body. CH................ S................. 0308 16.6001 $1,057.33 ........... $211.47
78890.............. Nuclear medicine data proc .................. N................. ........... ........... ........... ........... ...........
78891.............. Nuclear med data proc..... .................. N................. ........... ........... ........... ........... ...........
78999.............. Nuclear diagnostic exam... .................. S................. 0389 1.8190 $115.86 $33.81 $23.17
79005.............. Nuclear rx, oral admin.... .................. S................. 0407 3.3020 $210.32 $78.13 $42.06
79101.............. Nuclear rx, iv admin...... .................. S................. 0407 3.3020 $210.32 $78.13 $42.06
79200.............. Nuclear rx, intracav admin .................. S................. 0413 5.2741 $335.93 ........... $67.19
79300.............. Nuclr rx, interstit .................. S................. 0407 3.3020 $210.32 $78.13 $42.06
colloid.
79403.............. Hematopoietic nuclear tx.. .................. S................. 0413 5.2741 $335.93 ........... $67.19
79440.............. Nuclear rx, intra- .................. S................. 0413 5.2741 $335.93 ........... $67.19
articular.
79445.............. Nuclear rx, intra-arterial .................. S................. 0407 3.3020 $210.32 $78.13 $42.06
79999.............. Nuclear medicine therapy.. .................. S................. 0407 3.3020 $210.32 $78.13 $42.06
80047.............. Metabolic panel ionized ca NI................ A................. ........... ........... ........... ........... ...........
80048.............. Metabolic panel total ca.. .................. A................. ........... ........... ........... ........... ...........
80050.............. General health panel...... .................. E................. ........... ........... ........... ........... ...........
80051.............. Electrolyte panel......... .................. A................. ........... ........... ........... ........... ...........
80053.............. Comprehen metabolic panel. .................. A................. ........... ........... ........... ........... ...........
80055.............. Obstetric panel........... .................. E................. ........... ........... ........... ........... ...........
80061.............. Lipid panel............... .................. A................. ........... ........... ........... ........... ...........
80069.............. Renal function panel...... .................. A................. ........... ........... ........... ........... ...........
80074.............. Acute hepatitis panel..... .................. A................. ........... ........... ........... ........... ...........
80076.............. Hepatic function panel.... .................. A................. ........... ........... ........... ........... ...........
80100.............. Drug screen, qualitate/ .................. A................. ........... ........... ........... ........... ...........
multi.
80101.............. Drug screen, single....... .................. A................. ........... ........... ........... ........... ...........
80102.............. Drug confirmation......... .................. A................. ........... ........... ........... ........... ...........
80103.............. Drug analysis, tissue prep .................. N................. ........... ........... ........... ........... ...........
80150.............. Assay of amikacin......... .................. A................. ........... ........... ........... ........... ...........
80152.............. Assay of amitriptyline.... .................. A................. ........... ........... ........... ........... ...........
80154.............. Assay of benzodiazepines.. .................. A................. ........... ........... ........... ........... ...........
80156.............. Assay, carbamazepine, .................. A................. ........... ........... ........... ........... ...........
total.
80157.............. Assay, carbamazepine, free .................. A................. ........... ........... ........... ........... ...........
80158.............. Assay of cyclosporine..... .................. A................. ........... ........... ........... ........... ...........
80160.............. Assay of desipramine...... .................. A................. ........... ........... ........... ........... ...........
80162.............. Assay of digoxin.......... .................. A................. ........... ........... ........... ........... ...........
80164.............. Assay, dipropylacetic acid .................. A................. ........... ........... ........... ........... ...........
80166.............. Assay of doxepin.......... .................. A................. ........... ........... ........... ........... ...........
80168.............. Assay of ethosuximide..... .................. A................. ........... ........... ........... ........... ...........
80170.............. Assay of gentamicin....... .................. A................. ........... ........... ........... ........... ...........
80172.............. Assay of gold............. .................. A................. ........... ........... ........... ........... ...........
80173.............. Assay of haloperidol...... .................. A................. ........... ........... ........... ........... ...........
80174.............. Assay of imipramine....... .................. A................. ........... ........... ........... ........... ...........
80176.............. Assay of lidocaine........ .................. A................. ........... ........... ........... ........... ...........
80178.............. Assay of lithium.......... .................. A................. ........... ........... ........... ........... ...........
80182.............. Assay of nortriptyline.... .................. A................. ........... ........... ........... ........... ...........
80184.............. Assay of phenobarbital.... .................. A................. ........... ........... ........... ........... ...........
80185.............. Assay of phenytoin, total. .................. A................. ........... ........... ........... ........... ...........
80186.............. Assay of phenytoin, free.. .................. A................. ........... ........... ........... ........... ...........
[[Page 67080]]
80188.............. Assay of primidone........ .................. A................. ........... ........... ........... ........... ...........
80190.............. Assay of procainamide..... .................. A................. ........... ........... ........... ........... ...........
80192.............. Assay of procainamide..... .................. A................. ........... ........... ........... ........... ...........
80194.............. Assay of quinidine........ .................. A................. ........... ........... ........... ........... ...........
80195.............. Assay of sirolimus........ .................. A................. ........... ........... ........... ........... ...........
80196.............. Assay of salicylate....... .................. A................. ........... ........... ........... ........... ...........
80197.............. Assay of tacrolimus....... .................. A................. ........... ........... ........... ........... ...........
80198.............. Assay of theophylline..... .................. A................. ........... ........... ........... ........... ...........
80200.............. Assay of tobramycin....... .................. A................. ........... ........... ........... ........... ...........
80201.............. Assay of topiramate....... .................. A................. ........... ........... ........... ........... ...........
80202.............. Assay of vancomycin....... .................. A................. ........... ........... ........... ........... ...........
80299.............. Quantitative assay, drug.. .................. A................. ........... ........... ........... ........... ...........
80400.............. Acth stimulation panel.... .................. A................. ........... ........... ........... ........... ...........
80402.............. Acth stimulation panel.... .................. A................. ........... ........... ........... ........... ...........
80406.............. Acth stimulation panel.... .................. A................. ........... ........... ........... ........... ...........
80408.............. Aldosterone suppression .................. A................. ........... ........... ........... ........... ...........
eval.
80410.............. Calcitonin stimul panel... .................. A................. ........... ........... ........... ........... ...........
80412.............. CRH stimulation panel..... .................. A................. ........... ........... ........... ........... ...........
80414.............. Testosterone response..... .................. A................. ........... ........... ........... ........... ...........
80415.............. Estradiol response panel.. .................. A................. ........... ........... ........... ........... ...........
80416.............. Renin stimulation panel... .................. A................. ........... ........... ........... ........... ...........
80417.............. Renin stimulation panel... .................. A................. ........... ........... ........... ........... ...........
80418.............. Pituitary evaluation panel .................. A................. ........... ........... ........... ........... ...........
80420.............. Dexamethasone panel....... .................. A................. ........... ........... ........... ........... ...........
80422.............. Glucagon tolerance panel.. .................. A................. ........... ........... ........... ........... ...........
80424.............. Glucagon tolerance panel.. .................. A................. ........... ........... ........... ........... ...........
80426.............. Gonadotropin hormone panel .................. A................. ........... ........... ........... ........... ...........
80428.............. Growth hormone panel...... .................. A................. ........... ........... ........... ........... ...........
80430.............. Growth hormone panel...... .................. A................. ........... ........... ........... ........... ...........
80432.............. Insulin suppression panel. .................. A................. ........... ........... ........... ........... ...........
80434.............. Insulin tolerance panel... .................. A................. ........... ........... ........... ........... ...........
80435.............. Insulin tolerance panel... .................. A................. ........... ........... ........... ........... ...........
80436.............. Metyrapone panel.......... .................. A................. ........... ........... ........... ........... ...........
80438.............. TRH stimulation panel..... .................. A................. ........... ........... ........... ........... ...........
80439.............. TRH stimulation panel..... .................. A................. ........... ........... ........... ........... ...........
80440.............. TRH stimulation panel..... .................. A................. ........... ........... ........... ........... ...........
80500.............. Lab pathology consultation .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
80502.............. Lab pathology consultation .................. X................. 0342 0.0969 $6.17 $2.02 $1.23
81000.............. Urinalysis, nonauto w/ .................. A................. ........... ........... ........... ........... ...........
scope.
81001.............. Urinalysis, auto w/scope.. .................. A................. ........... ........... ........... ........... ...........
81002.............. Urinalysis nonauto w/o .................. A................. ........... ........... ........... ........... ...........
scope.
81003.............. Urinalysis, auto, w/o .................. A................. ........... ........... ........... ........... ...........
scope.
81005.............. Urinalysis................ .................. A................. ........... ........... ........... ........... ...........
81007.............. Urine screen for bacteria. .................. A................. ........... ........... ........... ........... ...........
81015.............. Microscopic exam of urine. .................. A................. ........... ........... ........... ........... ...........
81020.............. Urinalysis, glass test.... .................. A................. ........... ........... ........... ........... ...........
81025.............. Urine pregnancy test...... .................. A................. ........... ........... ........... ........... ...........
81050.............. Urinalysis, volume measure .................. A................. ........... ........... ........... ........... ...........
81099.............. Urinalysis test procedure. .................. A................. ........... ........... ........... ........... ...........
82000.............. Assay of blood .................. A................. ........... ........... ........... ........... ...........
acetaldehyde.
82003.............. Assay of acetaminophen.... .................. A................. ........... ........... ........... ........... ...........
82009.............. Test for acetone/ketones.. .................. A................. ........... ........... ........... ........... ...........
82010.............. Acetone assay............. .................. A................. ........... ........... ........... ........... ...........
82013.............. Acetylcholinesterase assay .................. A................. ........... ........... ........... ........... ...........
82016.............. Acylcarnitines, qual...... .................. A................. ........... ........... ........... ........... ...........
82017.............. Acylcarnitines, quant..... .................. A................. ........... ........... ........... ........... ...........
82024.............. Assay of acth............. .................. A................. ........... ........... ........... ........... ...........
82030.............. Assay of adp & amp........ .................. A................. ........... ........... ........... ........... ...........
82040.............. Assay of serum albumin.... .................. A................. ........... ........... ........... ........... ...........
82042.............. Assay of urine albumin.... .................. A................. ........... ........... ........... ........... ...........
82043.............. Microalbumin, quantitative .................. A................. ........... ........... ........... ........... ...........
82044.............. Microalbumin, semiquant... .................. A................. ........... ........... ........... ........... ...........
82045.............. Albumin, ischemia modified .................. A................. ........... ........... ........... ........... ...........
82055.............. Assay of ethanol.......... .................. A................. ........... ........... ........... ........... ...........
82075.............. Assay of breath ethanol... .................. A................. ........... ........... ........... ........... ...........
82085.............. Assay of aldolase......... .................. A................. ........... ........... ........... ........... ...........
82088.............. Assay of aldosterone...... .................. A................. ........... ........... ........... ........... ...........
82101.............. Assay of urine alkaloids.. .................. A................. ........... ........... ........... ........... ...........
82103.............. Alpha-1-antitrypsin, total .................. A................. ........... ........... ........... ........... ...........
82104.............. Alpha-1-antitrypsin, pheno .................. A................. ........... ........... ........... ........... ...........
82105.............. Alpha-fetoprotein, serum.. .................. A................. ........... ........... ........... ........... ...........
82106.............. Alpha-fetoprotein, .................. A................. ........... ........... ........... ........... ...........
amniotic.
82107.............. Alpha-fetoprotein l3...... .................. A................. ........... ........... ........... ........... ...........
82108.............. Assay of aluminum......... .................. A................. ........... ........... ........... ........... ...........
82120.............. Amines, vaginal fluid qual .................. A................. ........... ........... ........... ........... ...........
82127.............. Amino acid, single qual... .................. A................. ........... ........... ........... ........... ...........
82128.............. Amino acids, mult qual.... .................. A................. ........... ........... ........... ........... ...........
82131.............. Amino acids, single quant. .................. A................. ........... ........... ........... ........... ...........
82135.............. Assay, aminolevulinic acid .................. A................. ........... ........... ........... ........... ...........
82136.............. Amino acids, quant, 2-5... .................. A................. ........... ........... ........... ........... ...........
[[Page 67081]]
82139.............. Amino acids, quan, 6 or .................. A................. ........... ........... ........... ........... ...........
more.
82140.............. Assay of ammonia.......... .................. A................. ........... ........... ........... ........... ...........
82143.............. Amniotic fluid scan....... .................. A................. ........... ........... ........... ........... ...........
82145.............. Assay of amphetamines..... .................. A................. ........... ........... ........... ........... ...........
82150.............. Assay of amylase.......... .................. A................. ........... ........... ........... ........... ...........
82154.............. Androstanediol glucuronide .................. A................. ........... ........... ........... ........... ...........
82157.............. Assay of androstenedione.. .................. A................. ........... ........... ........... ........... ...........
82160.............. Assay of androsterone..... .................. A................. ........... ........... ........... ........... ...........
82163.............. Assay of angiotensin II... .................. A................. ........... ........... ........... ........... ...........
82164.............. Angiotensin I enzyme test. .................. A................. ........... ........... ........... ........... ...........
82172.............. Assay of apolipoprotein... .................. A................. ........... ........... ........... ........... ...........
82175.............. Assay of arsenic.......... .................. A................. ........... ........... ........... ........... ...........
82180.............. Assay of ascorbic acid.... .................. A................. ........... ........... ........... ........... ...........
82190.............. Atomic absorption......... .................. A................. ........... ........... ........... ........... ...........
82205.............. Assay of barbiturates..... .................. A................. ........... ........... ........... ........... ...........
82232.............. Assay of beta-2 protein... .................. A................. ........... ........... ........... ........... ...........
82239.............. Bile acids, total......... .................. A................. ........... ........... ........... ........... ...........
82240.............. Bile acids, cholylglycine. .................. A................. ........... ........... ........... ........... ...........
82247.............. Bilirubin, total.......... .................. A................. ........... ........... ........... ........... ...........
82248.............. Bilirubin, direct......... .................. A................. ........... ........... ........... ........... ...........
82252.............. Fecal bilirubin test...... .................. A................. ........... ........... ........... ........... ...........
82261.............. Assay of biotinidase...... .................. A................. ........... ........... ........... ........... ...........
82270.............. Occult blood, feces....... .................. A................. ........... ........... ........... ........... ...........
82271.............. Occult blood, other .................. A................. ........... ........... ........... ........... ...........
sources.
82272.............. Occult bld feces, 1-3 .................. A................. ........... ........... ........... ........... ...........
tests.
82274.............. Assay test for blood, .................. A................. ........... ........... ........... ........... ...........
fecal.
82286.............. Assay of bradykinin....... .................. A................. ........... ........... ........... ........... ...........
82300.............. Assay of cadmium.......... .................. A................. ........... ........... ........... ........... ...........
82306.............. Assay of vitamin D........ .................. A................. ........... ........... ........... ........... ...........
82307.............. Assay of vitamin D........ .................. A................. ........... ........... ........... ........... ...........
82308.............. Assay of calcitonin....... .................. A................. ........... ........... ........... ........... ...........
82310.............. Assay of calcium.......... .................. A................. ........... ........... ........... ........... ...........
82330.............. Assay of calcium.......... .................. A................. ........... ........... ........... ........... ...........
82331.............. Calcium infusion test..... .................. A................. ........... ........... ........... ........... ...........
82340.............. Assay of calcium in urine. .................. A................. ........... ........... ........... ........... ...........
82355.............. Calculus analysis, qual... .................. A................. ........... ........... ........... ........... ...........
82360.............. Calculus assay, quant..... .................. A................. ........... ........... ........... ........... ...........
82365.............. Calculus spectroscopy..... .................. A................. ........... ........... ........... ........... ...........
82370.............. X-ray assay, calculus..... .................. A................. ........... ........... ........... ........... ...........
82373.............. Assay, c-d transfer .................. A................. ........... ........... ........... ........... ...........
measure.
82374.............. Assay, blood carbon .................. A................. ........... ........... ........... ........... ...........
dioxide.
82375.............. Assay, blood carbon .................. A................. ........... ........... ........... ........... ...........
monoxide.
82376.............. Test for carbon monoxide.. .................. A................. ........... ........... ........... ........... ...........
82378.............. Carcinoembryonic antigen.. .................. A................. ........... ........... ........... ........... ...........
82379.............. Assay of carnitine........ .................. A................. ........... ........... ........... ........... ...........
82380.............. Assay of carotene......... .................. A................. ........... ........... ........... ........... ...........
82382.............. Assay, urine .................. A................. ........... ........... ........... ........... ...........
catecholamines.
82383.............. Assay, blood .................. A................. ........... ........... ........... ........... ...........
catecholamines.
82384.............. Assay, three .................. A................. ........... ........... ........... ........... ...........
catecholamines.
82387.............. Assay of cathepsin-d...... .................. A................. ........... ........... ........... ........... ...........
82390.............. Assay of ceruloplasmin.... .................. A................. ........... ........... ........... ........... ...........
82397.............. Chemiluminescent assay.... .................. A................. ........... ........... ........... ........... ...........
82415.............. Assay of chloramphenicol.. .................. A................. ........... ........... ........... ........... ...........
82435.............. Assay of blood chloride... .................. A................. ........... ........... ........... ........... ...........
82436.............. Assay of urine chloride... .................. A................. ........... ........... ........... ........... ...........
82438.............. Assay, other fluid .................. A................. ........... ........... ........... ........... ...........
chlorides.
82441.............. Test for .................. A................. ........... ........... ........... ........... ...........
chlorohydrocarbons.
82465.............. Assay, bld/serum .................. A................. ........... ........... ........... ........... ...........
cholesterol.
82480.............. Assay, serum .................. A................. ........... ........... ........... ........... ...........
cholinesterase.
82482.............. Assay, rbc cholinesterase. .................. A................. ........... ........... ........... ........... ...........
82485.............. Assay, chondroitin sulfate .................. A................. ........... ........... ........... ........... ...........
82486.............. Gas/liquid chromatography. .................. A................. ........... ........... ........... ........... ...........
82487.............. Paper chromatography...... .................. A................. ........... ........... ........... ........... ...........
82488.............. Paper chromatography...... .................. A................. ........... ........... ........... ........... ...........
82489.............. Thin layer chromatography. .................. A................. ........... ........... ........... ........... ...........
82491.............. Chromotography, quant, .................. A................. ........... ........... ........... ........... ...........
sing.
82492.............. Chromotography, quant, .................. A................. ........... ........... ........... ........... ...........
mult.
82495.............. Assay of chromium......... .................. A................. ........... ........... ........... ........... ...........
82507.............. Assay of citrate.......... .................. A................. ........... ........... ........... ........... ...........
82520.............. Assay of cocaine.......... .................. A................. ........... ........... ........... ........... ...........
82523.............. Collagen crosslinks....... .................. A................. ........... ........... ........... ........... ...........
82525.............. Assay of copper........... .................. A................. ........... ........... ........... ........... ...........
82528.............. Assay of corticosterone... .................. A................. ........... ........... ........... ........... ...........
82530.............. Cortisol, free............ .................. A................. ........... ........... ........... ........... ...........
82533.............. Total cortisol............ .................. A................. ........... ........... ........... ........... ...........
82540.............. Assay of creatine......... .................. A................. ........... ........... ........... ........... ...........
82541.............. Column chromotography, .................. A................. ........... ........... ........... ........... ...........
qual.
82542.............. Column chromotography, .................. A................. ........... ........... ........... ........... ...........
quant.
82543.............. Column chromotograph/ .................. A................. ........... ........... ........... ........... ...........
isotope.
82544.............. Column chromotograph/ .................. A................. ........... ........... ........... ........... ...........
isotope.
[[Page 67082]]
82550.............. Assay of ck (cpk)......... .................. A................. ........... ........... ........... ........... ...........
82552.............. Assay of cpk in blood..... .................. A................. ........... ........... ........... ........... ...........
82553.............. Creatine, MB fraction..... .................. A................. ........... ........... ........... ........... ...........
82554.............. Creatine, isoforms........ .................. A................. ........... ........... ........... ........... ...........
82565.............. Assay of creatinine....... .................. A................. ........... ........... ........... ........... ...........
82570.............. Assay of urine creatinine. .................. A................. ........... ........... ........... ........... ...........
82575.............. Creatinine clearance test. .................. A................. ........... ........... ........... ........... ...........
82585.............. Assay of cryofibrinogen... .................. A................. ........... ........... ........... ........... ...........
82595.............. Assay of cryoglobulin..... .................. A................. ........... ........... ........... ........... ...........
82600.............. Assay of cyanide.......... .................. A................. ........... ........... ........... ........... ...........
82607.............. Vitamin B-12.............. .................. A................. ........... ........... ........... ........... ...........
82608.............. B-12 binding capacity..... .................. A................. ........... ........... ........... ........... ...........
82610.............. Cystatin c................ NI................ A................. ........... ........... ........... ........... ...........
82615.............. Test for urine cystines... .................. A................. ........... ........... ........... ........... ...........
82626.............. Dehydroepiandrosterone.... .................. A................. ........... ........... ........... ........... ...........
82627.............. Dehydroepiandrosterone.... .................. A................. ........... ........... ........... ........... ...........
82633.............. Desoxycorticosterone...... .................. A................. ........... ........... ........... ........... ...........
82634.............. Deoxycortisol............. .................. A................. ........... ........... ........... ........... ...........
82638.............. Assay of dibucaine number. .................. A................. ........... ........... ........... ........... ...........
82646.............. Assay of dihydrocodeinone. .................. A................. ........... ........... ........... ........... ...........
82649.............. Assay of dihydromorphinone .................. A................. ........... ........... ........... ........... ...........
82651.............. Assay of .................. A................. ........... ........... ........... ........... ...........
dihydrotestosterone.
82652.............. Assay of dihydroxyvitamin .................. A................. ........... ........... ........... ........... ...........
d.
82654.............. Assay of dimethadione..... .................. A................. ........... ........... ........... ........... ...........
82656.............. Pancreatic elastase, fecal .................. A................. ........... ........... ........... ........... ...........
82657.............. Enzyme cell activity...... .................. A................. ........... ........... ........... ........... ...........
82658.............. Enzyme cell activity, ra.. .................. A................. ........... ........... ........... ........... ...........
82664.............. Electrophoretic test...... .................. A................. ........... ........... ........... ........... ...........
82666.............. Assay of epiandrosterone.. .................. A................. ........... ........... ........... ........... ...........
82668.............. Assay of erythropoietin... .................. A................. ........... ........... ........... ........... ...........
82670.............. Assay of estradiol........ .................. A................. ........... ........... ........... ........... ...........
82671.............. Assay of estrogens........ .................. A................. ........... ........... ........... ........... ...........
82672.............. Assay of estrogen......... .................. A................. ........... ........... ........... ........... ...........
82677.............. Assay of estriol.......... .................. A................. ........... ........... ........... ........... ...........
82679.............. Assay of estrone.......... .................. A................. ........... ........... ........... ........... ...........
82690.............. Assay of ethchlorvynol.... .................. A................. ........... ........... ........... ........... ...........
82693.............. Assay of ethylene glycol.. .................. A................. ........... ........... ........... ........... ...........
82696.............. Assay of etiocholanolone.. .................. A................. ........... ........... ........... ........... ...........
82705.............. Fats/lipids, feces, qual.. .................. A................. ........... ........... ........... ........... ...........
82710.............. Fats/lipids, feces, quant. .................. A................. ........... ........... ........... ........... ...........
82715.............. Assay of fecal fat........ .................. A................. ........... ........... ........... ........... ...........
82725.............. Assay of blood fatty acids .................. A................. ........... ........... ........... ........... ...........
82726.............. Long chain fatty acids.... .................. A................. ........... ........... ........... ........... ...........
82728.............. Assay of ferritin......... .................. A................. ........... ........... ........... ........... ...........
82731.............. Assay of fetal fibronectin .................. A................. ........... ........... ........... ........... ...........
82735.............. Assay of fluoride......... .................. A................. ........... ........... ........... ........... ...........
82742.............. Assay of flurazepam....... .................. A................. ........... ........... ........... ........... ...........
82746.............. Blood folic acid serum.... .................. A................. ........... ........... ........... ........... ...........
82747.............. Assay of folic acid, rbc.. .................. A................. ........... ........... ........... ........... ...........
82757.............. Assay of semen fructose... .................. A................. ........... ........... ........... ........... ...........
82759.............. Assay of rbc galactokinase .................. A................. ........... ........... ........... ........... ...........
82760.............. Assay of galactose........ .................. A................. ........... ........... ........... ........... ...........
82775.............. Assay galactose .................. A................. ........... ........... ........... ........... ...........
transferase.
82776.............. Galactose transferase test .................. A................. ........... ........... ........... ........... ...........
82784.............. Assay of gammaglobulin igm .................. A................. ........... ........... ........... ........... ...........
82785.............. Assay of gammaglobulin ige .................. A................. ........... ........... ........... ........... ...........
82787.............. Igg 1, 2, 3 or 4, each.... .................. A................. ........... ........... ........... ........... ...........
82800.............. Blood pH.................. .................. A................. ........... ........... ........... ........... ...........
82803.............. Blood gases: pH, pO2 & .................. A................. ........... ........... ........... ........... ...........
pCO2.
82805.............. Blood gases w/o2 .................. A................. ........... ........... ........... ........... ...........
saturation.
82810.............. Blood gases, O2 sat only.. .................. A................. ........... ........... ........... ........... ...........
82820.............. Hemoglobin-oxygen affinity .................. A................. ........... ........... ........... ........... ...........
82926.............. Assay of gastric acid..... .................. A................. ........... ........... ........... ........... ...........
82928.............. Assay of gastric acid..... .................. A................. ........... ........... ........... ........... ...........
82938.............. Gastrin test.............. .................. A................. ........... ........... ........... ........... ...........
82941.............. Assay of gastrin.......... .................. A................. ........... ........... ........... ........... ...........
82943.............. Assay of glucagon......... .................. A................. ........... ........... ........... ........... ...........
82945.............. Glucose other fluid....... .................. A................. ........... ........... ........... ........... ...........
82946.............. Glucagon tolerance test... .................. A................. ........... ........... ........... ........... ...........
82947.............. Assay, glucose, blood .................. A................. ........... ........... ........... ........... ...........
quant.
82948.............. Reagent strip/blood .................. A................. ........... ........... ........... ........... ...........
glucose.
82950.............. Glucose test.............. .................. A................. ........... ........... ........... ........... ...........
82951.............. Glucose tolerance test .................. A................. ........... ........... ........... ........... ...........
(GTT).
82952.............. GTT-added samples......... .................. A................. ........... ........... ........... ........... ...........
82953.............. Glucose-tolbutamide test.. .................. A................. ........... ........... ........... ........... ...........
82955.............. Assay of g6pd enzyme...... .................. A................. ........... ........... ........... ........... ...........
82960.............. Test for G6PD enzyme...... .................. A................. ........... ........... ........... ........... ...........
82962.............. Glucose blood test........ .................. A................. ........... ........... ........... ........... ...........
82963.............. Assay of glucosidase...... .................. A................. ........... ........... ........... ........... ...........
82965.............. Assay of gdh enzyme....... .................. A................. ........... ........... ........... ........... ...........
[[Page 67083]]
82975.............. Assay of glutamine........ .................. A................. ........... ........... ........... ........... ...........
82977.............. Assay of GGT.............. .................. A................. ........... ........... ........... ........... ...........
82978.............. Assay of glutathione...... .................. A................. ........... ........... ........... ........... ...........
82979.............. Assay, rbc glutathione.... .................. A................. ........... ........... ........... ........... ...........
82980.............. Assay of glutethimide..... .................. A................. ........... ........... ........... ........... ...........
82985.............. Glycated protein.......... .................. A................. ........... ........... ........... ........... ...........
83001.............. Gonadotropin (FSH)........ .................. A................. ........... ........... ........... ........... ...........
83002.............. Gonadotropin (LH)......... .................. A................. ........... ........... ........... ........... ...........
83003.............. Assay, growth hormone .................. A................. ........... ........... ........... ........... ...........
(hgh).
83008.............. Assay of guanosine........ .................. A................. ........... ........... ........... ........... ...........
83009.............. H pylori (c-13), blood.... .................. A................. ........... ........... ........... ........... ...........
83010.............. Assay of haptoglobin, .................. A................. ........... ........... ........... ........... ...........
quant.
83012.............. Assay of haptoglobins..... .................. A................. ........... ........... ........... ........... ...........
83013.............. H pylori (c-13), breath... .................. A................. ........... ........... ........... ........... ...........
83014.............. H pylori drug admin....... .................. A................. ........... ........... ........... ........... ...........
83015.............. Heavy metal screen........ .................. A................. ........... ........... ........... ........... ...........
83018.............. Quantitative screen, .................. A................. ........... ........... ........... ........... ...........
metals.
83020.............. Hemoglobin electrophoresis .................. A................. ........... ........... ........... ........... ...........
83021.............. Hemoglobin chromotography. .................. A................. ........... ........... ........... ........... ...........
83026.............. Hemoglobin, copper sulfate .................. A................. ........... ........... ........... ........... ...........
83030.............. Fetal hemoglobin, chemical .................. A................. ........... ........... ........... ........... ...........
83033.............. Fetal hemoglobin assay, .................. A................. ........... ........... ........... ........... ...........
qual.
83036.............. Glycosylated hemoglobin .................. A................. ........... ........... ........... ........... ...........
test.
83037.............. Glycosylated hb, home .................. A................. ........... ........... ........... ........... ...........
device.
83045.............. Blood methemoglobin test.. .................. A................. ........... ........... ........... ........... ...........
83050.............. Blood methemoglobin assay. .................. A................. ........... ........... ........... ........... ...........
83051.............. Assay of plasma hemoglobin .................. A................. ........... ........... ........... ........... ...........
83055.............. Blood sulfhemoglobin test. .................. A................. ........... ........... ........... ........... ...........
83060.............. Blood sulfhemoglobin assay .................. A................. ........... ........... ........... ........... ...........
83065.............. Assay of hemoglobin heat.. .................. A................. ........... ........... ........... ........... ...........
83068.............. Hemoglobin stability .................. A................. ........... ........... ........... ........... ...........
screen.
83069.............. Assay of urine hemoglobin. .................. A................. ........... ........... ........... ........... ...........
83070.............. Assay of hemosiderin, qual .................. A................. ........... ........... ........... ........... ...........
83071.............. Assay of hemosiderin, .................. A................. ........... ........... ........... ........... ...........
quant.
83080.............. Assay of b hexosaminidase. .................. A................. ........... ........... ........... ........... ...........
83088.............. Assay of histamine........ .................. A................. ........... ........... ........... ........... ...........
83090.............. Assay of homocystine...... .................. A................. ........... ........... ........... ........... ...........
83150.............. Assay of for hva.......... .................. A................. ........... ........... ........... ........... ...........
83491.............. Assay of corticosteroids.. .................. A................. ........... ........... ........... ........... ...........
83497.............. Assay of 5-hiaa........... .................. A................. ........... ........... ........... ........... ...........
83498.............. Assay of progesterone..... .................. A................. ........... ........... ........... ........... ...........
83499.............. Assay of progesterone..... .................. A................. ........... ........... ........... ........... ...........
83500.............. Assay, free hydroxyproline .................. A................. ........... ........... ........... ........... ...........
83505.............. Assay, total .................. A................. ........... ........... ........... ........... ...........
hydroxyproline.
83516.............. Immunoassay, nonantibody.. .................. A................. ........... ........... ........... ........... ...........
83518.............. Immunoassay, dipstick..... .................. A................. ........... ........... ........... ........... ...........
83519.............. Immunoassay, nonantibody.. .................. A................. ........... ........... ........... ........... ...........
83520.............. Immunoassay, RIA.......... .................. A................. ........... ........... ........... ........... ...........
83525.............. Assay of insulin.......... .................. A................. ........... ........... ........... ........... ...........
83527.............. Assay of insulin.......... .................. A................. ........... ........... ........... ........... ...........
83528.............. Assay of intrinsic factor. .................. A................. ........... ........... ........... ........... ...........
83540.............. Assay of iron............. .................. A................. ........... ........... ........... ........... ...........
83550.............. Iron binding test......... .................. A................. ........... ........... ........... ........... ...........
83570.............. Assay of idh enzyme....... .................. A................. ........... ........... ........... ........... ...........
83582.............. Assay of ketogenic .................. A................. ........... ........... ........... ........... ...........
steroids.
83586.............. Assay 17- ketosteroids.... .................. A................. ........... ........... ........... ........... ...........
83593.............. Fractionation, .................. A................. ........... ........... ........... ........... ...........
ketosteroids.
83605.............. Assay of lactic acid...... .................. A................. ........... ........... ........... ........... ...........
83615.............. Lactate (LD) (LDH) enzyme. .................. A................. ........... ........... ........... ........... ...........
83625.............. Assay of ldh enzymes...... .................. A................. ........... ........... ........... ........... ...........
83630.............. Lactoferrin, fecal (qual). .................. A................. ........... ........... ........... ........... ...........
83631.............. Lactoferrin, fecal (quant) .................. A................. ........... ........... ........... ........... ...........
83632.............. Placental lactogen........ .................. A................. ........... ........... ........... ........... ...........
83633.............. Test urine for lactose.... .................. A................. ........... ........... ........... ........... ...........
83634.............. Assay of urine for lactose .................. A................. ........... ........... ........... ........... ...........
83655.............. Assay of lead............. .................. A................. ........... ........... ........... ........... ...........
83661.............. L/s ratio, fetal lung..... .................. A................. ........... ........... ........... ........... ...........
83662.............. Foam stability, fetal lung .................. A................. ........... ........... ........... ........... ...........
83663.............. Fluoro polarize, fetal .................. A................. ........... ........... ........... ........... ...........
lung.
83664.............. Lamellar bdy, fetal lung.. .................. A................. ........... ........... ........... ........... ...........
83670.............. Assay of lap enzyme....... .................. A................. ........... ........... ........... ........... ...........
83690.............. Assay of lipase........... .................. A................. ........... ........... ........... ........... ...........
83695.............. Assay of lipoprotein(a)... .................. A................. ........... ........... ........... ........... ...........
83698.............. Assay lipoprotein pla2.... .................. A................. ........... ........... ........... ........... ...........
83700.............. Lipopro bld, .................. A................. ........... ........... ........... ........... ...........
electrophoretic.
83701.............. Lipoprotein bld, hr .................. A................. ........... ........... ........... ........... ...........
fraction.
83704.............. Lipoprotein, bld, by nmr.. .................. A................. ........... ........... ........... ........... ...........
83718.............. Assay of lipoprotein...... .................. A................. ........... ........... ........... ........... ...........
83719.............. Assay of blood lipoprotein .................. A................. ........... ........... ........... ........... ...........
83721.............. Assay of blood lipoprotein .................. A................. ........... ........... ........... ........... ...........
[[Page 67084]]
83727.............. Assay of lrh hormone...... .................. A................. ........... ........... ........... ........... ...........
83735.............. Assay of magnesium........ .................. A................. ........... ........... ........... ........... ...........
83775.............. Assay of md enzyme........ .................. A................. ........... ........... ........... ........... ...........
83785.............. Assay of manganese........ .................. A................. ........... ........... ........... ........... ...........
83788.............. Mass spectrometry qual.... .................. A................. ........... ........... ........... ........... ...........
83789.............. Mass spectrometry quant... .................. A................. ........... ........... ........... ........... ...........
83805.............. Assay of meprobamate...... .................. A................. ........... ........... ........... ........... ...........
83825.............. Assay of mercury.......... .................. A................. ........... ........... ........... ........... ...........
83835.............. Assay of metanephrines.... .................. A................. ........... ........... ........... ........... ...........
83840.............. Assay of methadone........ .................. A................. ........... ........... ........... ........... ...........
83857.............. Assay of methemalbumin.... .................. A................. ........... ........... ........... ........... ...........
83858.............. Assay of methsuximide..... .................. A................. ........... ........... ........... ........... ...........
83864.............. Mucopolysaccharides....... .................. A................. ........... ........... ........... ........... ...........
83866.............. Mucopolysaccharides screen .................. A................. ........... ........... ........... ........... ...........
83872.............. Assay synovial fluid mucin .................. A................. ........... ........... ........... ........... ...........
83873.............. Assay of csf protein...... .................. A................. ........... ........... ........... ........... ...........
83874.............. Assay of myoglobin........ .................. A................. ........... ........... ........... ........... ...........
83880.............. Natriuretic peptide....... .................. A................. ........... ........... ........... ........... ...........
83883.............. Assay, nephelometry not .................. A................. ........... ........... ........... ........... ...........
spec.
83885.............. Assay of nickel........... .................. A................. ........... ........... ........... ........... ...........
83887.............. Assay of nicotine......... .................. A................. ........... ........... ........... ........... ...........
83890.............. Molecule isolate.......... .................. A................. ........... ........... ........... ........... ...........
83891.............. Molecule isolate nucleic.. .................. A................. ........... ........... ........... ........... ...........
83892.............. Molecular diagnostics..... .................. A................. ........... ........... ........... ........... ...........
83893.............. Molecule dot/slot/blot.... .................. A................. ........... ........... ........... ........... ...........
83894.............. Molecule gel electrophor.. .................. A................. ........... ........... ........... ........... ...........
83896.............. Molecular diagnostics..... .................. A................. ........... ........... ........... ........... ...........
83897.............. Molecule nucleic transfer. .................. A................. ........... ........... ........... ........... ...........
83898.............. Molecule nucleic ampli, .................. A................. ........... ........... ........... ........... ...........
each.
83900.............. Molecule nucleic ampli 2 .................. A................. ........... ........... ........... ........... ...........
seq.
83901.............. Molecule nucleic ampli .................. A................. ........... ........... ........... ........... ...........
addon.
83902.............. Molecular diagnostics..... .................. A................. ........... ........... ........... ........... ...........
83903.............. Molecule mutation scan.... .................. A................. ........... ........... ........... ........... ...........
83904.............. Molecule mutation identify .................. A................. ........... ........... ........... ........... ...........
83905.............. Molecule mutation identify .................. A................. ........... ........... ........... ........... ...........
83906.............. Molecule mutation identify .................. A................. ........... ........... ........... ........... ...........
83907.............. Lyse cells for nucleic ext .................. A................. ........... ........... ........... ........... ...........
83908.............. Nucleic acid, signal ampli .................. A................. ........... ........... ........... ........... ...........
83909.............. Nucleic acid, high .................. A................. ........... ........... ........... ........... ...........
resolute.
83912.............. Genetic examination....... .................. A................. ........... ........... ........... ........... ...........
83913.............. Molecular, rna .................. A................. ........... ........... ........... ........... ...........
stabilization.
83914.............. Mutation ident ola/sbce/ .................. A................. ........... ........... ........... ........... ...........
aspe.
83915.............. Assay of nucleotidase..... .................. A................. ........... ........... ........... ........... ...........
83916.............. Oligoclonal bands......... .................. A................. ........... ........... ........... ........... ...........
83918.............. Organic acids, total, .................. A................. ........... ........... ........... ........... ...........
quant.
83919.............. Organic acids, qual, each. .................. A................. ........... ........... ........... ........... ...........
83921.............. Organic acid, single, .................. A................. ........... ........... ........... ........... ...........
quant.
83925.............. Assay of opiates.......... .................. A................. ........... ........... ........... ........... ...........
83930.............. Assay of blood osmolality. .................. A................. ........... ........... ........... ........... ...........
83935.............. Assay of urine osmolality. .................. A................. ........... ........... ........... ........... ...........
83937.............. Assay of osteocalcin...... .................. A................. ........... ........... ........... ........... ...........
83945.............. Assay of oxalate.......... .................. A................. ........... ........... ........... ........... ...........
83950.............. Oncoprotein, her-2/neu.... .................. A................. ........... ........... ........... ........... ...........
83970.............. Assay of parathormone..... .................. A................. ........... ........... ........... ........... ...........
83986.............. Assay of body fluid .................. A................. ........... ........... ........... ........... ...........
acidity.
83992.............. Assay for phencyclidine... .................. A................. ........... ........... ........... ........... ...........
83993.............. Assay for calprotectin NI................ A................. ........... ........... ........... ........... ...........
fecal.
84022.............. Assay of phenothiazine.... .................. A................. ........... ........... ........... ........... ...........
84030.............. Assay of blood pku........ .................. A................. ........... ........... ........... ........... ...........
84035.............. Assay of phenylketones.... .................. A................. ........... ........... ........... ........... ...........
84060.............. Assay acid phosphatase.... .................. A................. ........... ........... ........... ........... ...........
84061.............. Phosphatase, forensic exam .................. A................. ........... ........... ........... ........... ...........
84066.............. Assay prostate phosphatase .................. A................. ........... ........... ........... ........... ...........
84075.............. Assay alkaline phosphatase .................. A................. ........... ........... ........... ........... ...........
84078.............. Assay alkaline phosphatase .................. A................. ........... ........... ........... ........... ...........
84080.............. Assay alkaline .................. A................. ........... ........... ........... ........... ...........
phosphatases.
84081.............. Amniotic fluid enzyme test .................. A................. ........... ........... ........... ........... ...........
84085.............. Assay of rbc pg6d enzyme.. .................. A................. ........... ........... ........... ........... ...........
84087.............. Assay phosphohexose .................. A................. ........... ........... ........... ........... ...........
enzymes.
84100.............. Assay of phosphorus....... .................. A................. ........... ........... ........... ........... ...........
84105.............. Assay of urine phosphorus. .................. A................. ........... ........... ........... ........... ...........
84106.............. Test for porphobilinogen.. .................. A................. ........... ........... ........... ........... ...........
84110.............. Assay of porphobilinogen.. .................. A................. ........... ........... ........... ........... ...........
84119.............. Test urine for porphyrins. .................. A................. ........... ........... ........... ........... ...........
84120.............. Assay of urine porphyrins. .................. A................. ........... ........... ........... ........... ...........
84126.............. Assay of feces porphyrins. .................. A................. ........... ........... ........... ........... ...........
84127.............. Assay of feces porphyrins. .................. A................. ........... ........... ........... ........... ...........
84132.............. Assay of serum potassium.. .................. A................. ........... ........... ........... ........... ...........
84133.............. Assay of urine potassium.. .................. A................. ........... ........... ........... ........... ...........
84134.............. Assay of prealbumin....... .................. A................. ........... ........... ........... ........... ...........
[[Page 67085]]
84135.............. Assay of pregnanediol..... .................. A................. ........... ........... ........... ........... ...........
84138.............. Assay of pregnanetriol.... .................. A................. ........... ........... ........... ........... ...........
84140.............. Assay of pregnenolone..... .................. A................. ........... ........... ........... ........... ...........
84143.............. Assay of 17- .................. A................. ........... ........... ........... ........... ...........
hydroxypregneno.
84144.............. Assay of progesterone..... .................. A................. ........... ........... ........... ........... ...........
84146.............. Assay of prolactin........ .................. A................. ........... ........... ........... ........... ...........
84150.............. Assay of prostaglandin.... .................. A................. ........... ........... ........... ........... ...........
84152.............. Assay of psa, complexed... .................. A................. ........... ........... ........... ........... ...........
84153.............. Assay of psa, total....... .................. A................. ........... ........... ........... ........... ...........
84154.............. Assay of psa, free........ .................. A................. ........... ........... ........... ........... ...........
84155.............. Assay of protein, serum... .................. A................. ........... ........... ........... ........... ...........
84156.............. Assay of protein, urine... .................. A................. ........... ........... ........... ........... ...........
84157.............. Assay of protein, other... .................. A................. ........... ........... ........... ........... ...........
84160.............. Assay of protein, any .................. A................. ........... ........... ........... ........... ...........
source.
84163.............. Pappa, serum.............. .................. A................. ........... ........... ........... ........... ...........
84165.............. Protein e-phoresis, serum. .................. A................. ........... ........... ........... ........... ...........
84166.............. Protein e-phoresis/urine/ .................. A................. ........... ........... ........... ........... ...........
csf.
84181.............. Western blot test......... .................. A................. ........... ........... ........... ........... ...........
84182.............. Protein, western blot test .................. A................. ........... ........... ........... ........... ...........
84202.............. Assay RBC protoporphyrin.. .................. A................. ........... ........... ........... ........... ...........
84203.............. Test RBC protoporphyrin... .................. A................. ........... ........... ........... ........... ...........
84206.............. Assay of proinsulin....... .................. A................. ........... ........... ........... ........... ...........
84207.............. Assay of vitamin b-6...... .................. A................. ........... ........... ........... ........... ...........
84210.............. Assay of pyruvate......... .................. A................. ........... ........... ........... ........... ...........
84220.............. Assay of pyruvate kinase.. .................. A................. ........... ........... ........... ........... ...........
84228.............. Assay of quinine.......... .................. A................. ........... ........... ........... ........... ...........
84233.............. Assay of estrogen......... .................. A................. ........... ........... ........... ........... ...........
84234.............. Assay of progesterone..... .................. A................. ........... ........... ........... ........... ...........
84235.............. Assay of endocrine hormone .................. A................. ........... ........... ........... ........... ...........
84238.............. Assay, nonendocrine .................. A................. ........... ........... ........... ........... ...........
receptor.
84244.............. Assay of renin............ .................. A................. ........... ........... ........... ........... ...........
84252.............. Assay of vitamin b-2...... .................. A................. ........... ........... ........... ........... ...........
84255.............. Assay of selenium......... .................. A................. ........... ........... ........... ........... ...........
84260.............. Assay of serotonin........ .................. A................. ........... ........... ........... ........... ...........
84270.............. Assay of sex hormone .................. A................. ........... ........... ........... ........... ...........
globul.
84275.............. Assay of sialic acid...... .................. A................. ........... ........... ........... ........... ...........
84285.............. Assay of silica........... .................. A................. ........... ........... ........... ........... ...........
84295.............. Assay of serum sodium..... .................. A................. ........... ........... ........... ........... ...........
84300.............. Assay of urine sodium..... .................. A................. ........... ........... ........... ........... ...........
84302.............. Assay of sweat sodium..... .................. A................. ........... ........... ........... ........... ...........
84305.............. Assay of somatomedin...... .................. A................. ........... ........... ........... ........... ...........
84307.............. Assay of somatostatin..... .................. A................. ........... ........... ........... ........... ...........
84311.............. Spectrophotometry......... .................. A................. ........... ........... ........... ........... ...........
84315.............. Body fluid specific .................. A................. ........... ........... ........... ........... ...........
gravity.
84375.............. Chromatogram assay, sugars .................. A................. ........... ........... ........... ........... ...........
84376.............. Sugars, single, qual...... .................. A................. ........... ........... ........... ........... ...........
84377.............. Sugars, multiple, qual.... .................. A................. ........... ........... ........... ........... ...........
84378.............. Sugars, single, quant..... .................. A................. ........... ........... ........... ........... ...........
84379.............. Sugars multiple quant..... .................. A................. ........... ........... ........... ........... ...........
84392.............. Assay of urine sulfate.... .................. A................. ........... ........... ........... ........... ...........
84402.............. Assay of testosterone..... .................. A................. ........... ........... ........... ........... ...........
84403.............. Assay of total .................. A................. ........... ........... ........... ........... ...........
testosterone.
84425.............. Assay of vitamin b-1...... .................. A................. ........... ........... ........... ........... ...........
84430.............. Assay of thiocyanate...... .................. A................. ........... ........... ........... ........... ...........
84432.............. Assay of thyroglobulin.... .................. A................. ........... ........... ........... ........... ...........
84436.............. Assay of total thyroxine.. .................. A................. ........... ........... ........... ........... ...........
84437.............. Assay of neonatal .................. A................. ........... ........... ........... ........... ...........
thyroxine.
84439.............. Assay of free thyroxine... .................. A................. ........... ........... ........... ........... ...........
84442.............. Assay of thyroid activity. .................. A................. ........... ........... ........... ........... ...........
84443.............. Assay thyroid stim hormone .................. A................. ........... ........... ........... ........... ...........
84445.............. Assay of tsi.............. .................. A................. ........... ........... ........... ........... ...........
84446.............. Assay of vitamin e........ .................. A................. ........... ........... ........... ........... ...........
84449.............. Assay of transcortin...... .................. A................. ........... ........... ........... ........... ...........
84450.............. Transferase (AST) (SGOT).. .................. A................. ........... ........... ........... ........... ...........
84460.............. Alanine amino (ALT) (SGPT) .................. A................. ........... ........... ........... ........... ...........
84466.............. Assay of transferrin...... .................. A................. ........... ........... ........... ........... ...........
84478.............. Assay of triglycerides.... .................. A................. ........... ........... ........... ........... ...........
84479.............. Assay of thyroid (t3 or .................. A................. ........... ........... ........... ........... ...........
t4).
84480.............. Assay, triiodothyronine .................. A................. ........... ........... ........... ........... ...........
(t3).
84481.............. Free assay (FT-3)......... .................. A................. ........... ........... ........... ........... ...........
84482.............. T3 reverse................ .................. A................. ........... ........... ........... ........... ...........
84484.............. Assay of troponin, quant.. .................. A................. ........... ........... ........... ........... ...........
84485.............. Assay duodenal fluid .................. A................. ........... ........... ........... ........... ...........
trypsin.
84488.............. Test feces for trypsin.... .................. A................. ........... ........... ........... ........... ...........
84490.............. Assay of feces for trypsin .................. A................. ........... ........... ........... ........... ...........
84510.............. Assay of tyrosine......... .................. A................. ........... ........... ........... ........... ...........
84512.............. Assay of troponin, qual... .................. A................. ........... ........... ........... ........... ...........
84520.............. Assay of urea nitrogen.... .................. A................. ........... ........... ........... ........... ...........
84525.............. Urea nitrogen semi-quant.. .................. A................. ........... ........... ........... ........... ...........
84540.............. Assay of urine/urea-n..... .................. A................. ........... ........... ........... ........... ...........
[[Page 67086]]
84545.............. Urea-N clearance test..... .................. A................. ........... ........... ........... ........... ...........
84550.............. Assay of blood/uric acid.. .................. A................. ........... ........... ........... ........... ...........
84560.............. Assay of urine/uric acid.. .................. A................. ........... ........... ........... ........... ...........
84577.............. Assay of feces/ .................. A................. ........... ........... ........... ........... ...........
urobilinogen.
84578.............. Test urine urobilinogen... .................. A................. ........... ........... ........... ........... ...........
84580.............. Assay of urine .................. A................. ........... ........... ........... ........... ...........
urobilinogen.
84583.............. Assay of urine .................. A................. ........... ........... ........... ........... ...........
urobilinogen.
84585.............. Assay of urine vma........ .................. A................. ........... ........... ........... ........... ...........
84586.............. Assay of vip.............. .................. A................. ........... ........... ........... ........... ...........
84588.............. Assay of vasopressin...... .................. A................. ........... ........... ........... ........... ...........
84590.............. Assay of vitamin a........ .................. A................. ........... ........... ........... ........... ...........
84591.............. Assay of nos vitamin...... .................. A................. ........... ........... ........... ........... ...........
84597.............. Assay of vitamin k........ .................. A................. ........... ........... ........... ........... ...........
84600.............. Assay of volatiles........ .................. A................. ........... ........... ........... ........... ...........
84620.............. Xylose tolerance test..... .................. A................. ........... ........... ........... ........... ...........
84630.............. Assay of zinc............. .................. A................. ........... ........... ........... ........... ...........
84681.............. Assay of c-peptide........ .................. A................. ........... ........... ........... ........... ...........
84702.............. Chorionic gonadotropin .................. A................. ........... ........... ........... ........... ...........
test.
84703.............. Chorionic gonadotropin .................. A................. ........... ........... ........... ........... ...........
assay.
84704.............. Hcg, free betachain test.. NI................ A................. ........... ........... ........... ........... ...........
84830.............. Ovulation tests........... .................. A................. ........... ........... ........... ........... ...........
84999.............. Clinical chemistry test... .................. A................. ........... ........... ........... ........... ...........
85002.............. Bleeding time test........ .................. A................. ........... ........... ........... ........... ...........
85004.............. Automated diff wbc count.. .................. A................. ........... ........... ........... ........... ...........
85007.............. Bl smear w/diff wbc count. .................. A................. ........... ........... ........... ........... ...........
85008.............. Bl smear w/o diff wbc .................. A................. ........... ........... ........... ........... ...........
count.
85009.............. Manual diff wbc count b- .................. A................. ........... ........... ........... ........... ...........
coat.
85013.............. Spun microhematocrit...... .................. A................. ........... ........... ........... ........... ...........
85014.............. Hematocrit................ .................. A................. ........... ........... ........... ........... ...........
85018.............. Hemoglobin................ .................. A................. ........... ........... ........... ........... ...........
85025.............. Complete cbc w/auto diff .................. A................. ........... ........... ........... ........... ...........
wbc.
85027.............. Complete cbc, automated... .................. A................. ........... ........... ........... ........... ...........
85032.............. Manual cell count, each... .................. A................. ........... ........... ........... ........... ...........
85041.............. Automated rbc count....... .................. A................. ........... ........... ........... ........... ...........
85044.............. Manual reticulocyte count. .................. A................. ........... ........... ........... ........... ...........
85045.............. Automated reticulocyte .................. A................. ........... ........... ........... ........... ...........
count.
85046.............. Reticyte/hgb concentrate.. .................. A................. ........... ........... ........... ........... ...........
85048.............. Automated leukocyte count. .................. A................. ........... ........... ........... ........... ...........
85049.............. Automated platelet count.. .................. A................. ........... ........... ........... ........... ...........
85055.............. Reticulated platelet assay .................. A................. ........... ........... ........... ........... ...........
85060.............. Blood smear interpretation .................. B................. ........... ........... ........... ........... ...........
85097.............. Bone marrow interpretation .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
85130.............. Chromogenic substrate .................. A................. ........... ........... ........... ........... ...........
assay.
85170.............. Blood clot retraction..... .................. A................. ........... ........... ........... ........... ...........
85175.............. Blood clot lysis time..... .................. A................. ........... ........... ........... ........... ...........
85210.............. Blood clot factor II test. .................. A................. ........... ........... ........... ........... ...........
85220.............. Blood clot factor V test.. .................. A................. ........... ........... ........... ........... ...........
85230.............. Blood clot factor VII test .................. A................. ........... ........... ........... ........... ...........
85240.............. Blood clot factor VIII .................. A................. ........... ........... ........... ........... ...........
test.
85244.............. Blood clot factor VIII .................. A................. ........... ........... ........... ........... ...........
test.
85245.............. Blood clot factor VIII .................. A................. ........... ........... ........... ........... ...........
test.
85246.............. Blood clot factor VIII .................. A................. ........... ........... ........... ........... ...........
test.
85247.............. Blood clot factor VIII .................. A................. ........... ........... ........... ........... ...........
test.
85250.............. Blood clot factor IX test. .................. A................. ........... ........... ........... ........... ...........
85260.............. Blood clot factor X test.. .................. A................. ........... ........... ........... ........... ...........
85270.............. Blood clot factor XI test. .................. A................. ........... ........... ........... ........... ...........
85280.............. Blood clot factor XII test .................. A................. ........... ........... ........... ........... ...........
85290.............. Blood clot factor XIII .................. A................. ........... ........... ........... ........... ...........
test.
85291.............. Blood clot factor XIII .................. A................. ........... ........... ........... ........... ...........
test.
85292.............. Blood clot factor assay... .................. A................. ........... ........... ........... ........... ...........
85293.............. Blood clot factor assay... .................. A................. ........... ........... ........... ........... ...........
85300.............. Antithrombin III test..... .................. A................. ........... ........... ........... ........... ...........
85301.............. Antithrombin III test..... .................. A................. ........... ........... ........... ........... ...........
85302.............. Blood clot inhibitor .................. A................. ........... ........... ........... ........... ...........
antigen.
85303.............. Blood clot inhibitor test. .................. A................. ........... ........... ........... ........... ...........
85305.............. Blood clot inhibitor assay .................. A................. ........... ........... ........... ........... ...........
85306.............. Blood clot inhibitor test. .................. A................. ........... ........... ........... ........... ...........
85307.............. Assay activated protein c. .................. A................. ........... ........... ........... ........... ...........
85335.............. Factor inhibitor test..... .................. A................. ........... ........... ........... ........... ...........
85337.............. Thrombomodulin............ .................. A................. ........... ........... ........... ........... ...........
85345.............. Coagulation time.......... .................. A................. ........... ........... ........... ........... ...........
85347.............. Coagulation time.......... .................. A................. ........... ........... ........... ........... ...........
85348.............. Coagulation time.......... .................. A................. ........... ........... ........... ........... ...........
85360.............. Euglobulin lysis.......... .................. A................. ........... ........... ........... ........... ...........
85362.............. Fibrin degradation .................. A................. ........... ........... ........... ........... ...........
products.
85366.............. Fibrinogen test........... .................. A................. ........... ........... ........... ........... ...........
85370.............. Fibrinogen test........... .................. A................. ........... ........... ........... ........... ...........
85378.............. Fibrin degrade, semiquant. .................. A................. ........... ........... ........... ........... ...........
85379.............. Fibrin degradation, quant. .................. A................. ........... ........... ........... ........... ...........
85380.............. Fibrin degradation, vte... .................. A................. ........... ........... ........... ........... ...........
[[Page 67087]]
85384.............. Fibrinogen................ .................. A................. ........... ........... ........... ........... ...........
85385.............. Fibrinogen................ .................. A................. ........... ........... ........... ........... ...........
85390.............. Fibrinolysins screen...... .................. A................. ........... ........... ........... ........... ...........
85396.............. Clotting assay, whole .................. N................. ........... ........... ........... ........... ...........
blood.
85400.............. Fibrinolytic plasmin...... .................. A................. ........... ........... ........... ........... ...........
85410.............. Fibrinolytic antiplasmin.. .................. A................. ........... ........... ........... ........... ...........
85415.............. Fibrinolytic plasminogen.. .................. A................. ........... ........... ........... ........... ...........
85420.............. Fibrinolytic plasminogen.. .................. A................. ........... ........... ........... ........... ...........
85421.............. Fibrinolytic plasminogen.. .................. A................. ........... ........... ........... ........... ...........
85441.............. Heinz bodies, direct...... .................. A................. ........... ........... ........... ........... ...........
85445.............. Heinz bodies, induced..... .................. A................. ........... ........... ........... ........... ...........
85460.............. Hemoglobin, fetal......... .................. A................. ........... ........... ........... ........... ...........
85461.............. Hemoglobin, fetal......... .................. A................. ........... ........... ........... ........... ...........
85475.............. Hemolysin................. .................. A................. ........... ........... ........... ........... ...........
85520.............. Heparin assay............. .................. A................. ........... ........... ........... ........... ...........
85525.............. Heparin neutralization.... .................. A................. ........... ........... ........... ........... ...........
85530.............. Heparin-protamine .................. A................. ........... ........... ........... ........... ...........
tolerance.
85536.............. Iron stain peripheral .................. A................. ........... ........... ........... ........... ...........
blood.
85540.............. Wbc alkaline phosphatase.. .................. A................. ........... ........... ........... ........... ...........
85547.............. RBC mechanical fragility.. .................. A................. ........... ........... ........... ........... ...........
85549.............. Muramidase................ .................. A................. ........... ........... ........... ........... ...........
85555.............. RBC osmotic fragility..... .................. A................. ........... ........... ........... ........... ...........
85557.............. RBC osmotic fragility..... .................. A................. ........... ........... ........... ........... ...........
85576.............. Blood platelet aggregation .................. A................. ........... ........... ........... ........... ...........
85597.............. Platelet neutralization... .................. A................. ........... ........... ........... ........... ...........
85610.............. Prothrombin time.......... .................. A................. ........... ........... ........... ........... ...........
85611.............. Prothrombin test.......... .................. A................. ........... ........... ........... ........... ...........
85612.............. Viper venom prothrombin .................. A................. ........... ........... ........... ........... ...........
time.
85613.............. Russell viper venom, .................. A................. ........... ........... ........... ........... ...........
diluted.
85635.............. Reptilase test............ .................. A................. ........... ........... ........... ........... ...........
85651.............. Rbc sed rate, nonautomated .................. A................. ........... ........... ........... ........... ...........
85652.............. Rbc sed rate, automated... .................. A................. ........... ........... ........... ........... ...........
85660.............. RBC sickle cell test...... .................. A................. ........... ........... ........... ........... ...........
85670.............. Thrombin time, plasma..... .................. A................. ........... ........... ........... ........... ...........
85675.............. Thrombin time, titer...... .................. A................. ........... ........... ........... ........... ...........
85705.............. Thromboplastin inhibition. .................. A................. ........... ........... ........... ........... ...........
85730.............. Thromboplastin time, .................. A................. ........... ........... ........... ........... ...........
partial.
85732.............. Thromboplastin time, .................. A................. ........... ........... ........... ........... ...........
partial.
85810.............. Blood viscosity .................. A................. ........... ........... ........... ........... ...........
examination.
85999.............. Hematology procedure...... .................. A................. ........... ........... ........... ........... ...........
86000.............. Agglutinins, febrile...... .................. A................. ........... ........... ........... ........... ...........
86001.............. Allergen specific igg..... .................. A................. ........... ........... ........... ........... ...........
86003.............. Allergen specific IgE..... .................. A................. ........... ........... ........... ........... ...........
86005.............. Allergen specific IgE..... .................. A................. ........... ........... ........... ........... ...........
86021.............. WBC antibody .................. A................. ........... ........... ........... ........... ...........
identification.
86022.............. Platelet antibodies....... .................. A................. ........... ........... ........... ........... ...........
86023.............. Immunoglobulin assay...... .................. A................. ........... ........... ........... ........... ...........
86038.............. Antinuclear antibodies.... .................. A................. ........... ........... ........... ........... ...........
86039.............. Antinuclear antibodies .................. A................. ........... ........... ........... ........... ...........
(ANA).
86060.............. Antistreptolysin o, titer. .................. A................. ........... ........... ........... ........... ...........
86063.............. Antistreptolysin o, screen .................. A................. ........... ........... ........... ........... ...........
86077.............. Physician blood bank .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
service.
86078.............. Physician blood bank .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
service.
86079.............. Physician blood bank .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
service.
86140.............. C-reactive protein........ .................. A................. ........... ........... ........... ........... ...........
86141.............. C-reactive protein, hs.... .................. A................. ........... ........... ........... ........... ...........
86146.............. Glycoprotein antibody..... .................. A................. ........... ........... ........... ........... ...........
86147.............. Cardiolipin antibody...... .................. A................. ........... ........... ........... ........... ...........
86148.............. Phospholipid antibody..... .................. A................. ........... ........... ........... ........... ...........
86155.............. Chemotaxis assay.......... .................. A................. ........... ........... ........... ........... ...........
86156.............. Cold agglutinin, screen... .................. A................. ........... ........... ........... ........... ...........
86157.............. Cold agglutinin, titer.... .................. A................. ........... ........... ........... ........... ...........
86160.............. Complement, antigen....... .................. A................. ........... ........... ........... ........... ...........
86161.............. Complement/function .................. A................. ........... ........... ........... ........... ...........
activity.
86162.............. Complement, total (CH50).. .................. A................. ........... ........... ........... ........... ...........
86171.............. Complement fixation, each. .................. A................. ........... ........... ........... ........... ...........
86185.............. Counterimmunoelectrophores .................. A................. ........... ........... ........... ........... ...........
is.
86200.............. Ccp antibody.............. .................. A................. ........... ........... ........... ........... ...........
86215.............. Deoxyribonuclease, .................. A................. ........... ........... ........... ........... ...........
antibody.
86225.............. DNA antibody.............. .................. A................. ........... ........... ........... ........... ...........
86226.............. DNA antibody, single .................. A................. ........... ........... ........... ........... ...........
strand.
86235.............. Nuclear antigen antibody.. .................. A................. ........... ........... ........... ........... ...........
86243.............. Fc receptor............... .................. A................. ........... ........... ........... ........... ...........
86255.............. Fluorescent antibody, .................. A................. ........... ........... ........... ........... ...........
screen.
86256.............. Fluorescent antibody, .................. A................. ........... ........... ........... ........... ...........
titer.
86277.............. Growth hormone antibody... .................. A................. ........... ........... ........... ........... ...........
86280.............. Hemagglutination .................. A................. ........... ........... ........... ........... ...........
inhibition.
86294.............. Immunoassay, tumor, qual.. .................. A................. ........... ........... ........... ........... ...........
86300.............. Immunoassay, tumor, ca 15- .................. A................. ........... ........... ........... ........... ...........
3.
86301.............. Immunoassay, tumor, ca 19- .................. A................. ........... ........... ........... ........... ...........
9.
[[Page 67088]]
86304.............. Immunoassay, tumor, ca 125 .................. A................. ........... ........... ........... ........... ...........
86308.............. Heterophile antibodies.... .................. A................. ........... ........... ........... ........... ...........
86309.............. Heterophile antibodies.... .................. A................. ........... ........... ........... ........... ...........
86310.............. Heterophile antibodies.... .................. A................. ........... ........... ........... ........... ...........
86316.............. Immunoassay, tumor other.. .................. A................. ........... ........... ........... ........... ...........
86317.............. Immunoassay,infectious .................. A................. ........... ........... ........... ........... ...........
agent.
86318.............. Immunoassay,infectious .................. A................. ........... ........... ........... ........... ...........
agent.
86320.............. Serum .................. A................. ........... ........... ........... ........... ...........
immunoelectrophoresis.
86325.............. Other .................. A................. ........... ........... ........... ........... ...........
immunoelectrophoresis.
86327.............. Immunoelectrophoresis .................. A................. ........... ........... ........... ........... ...........
assay.
86329.............. Immunodiffusion........... .................. A................. ........... ........... ........... ........... ...........
86331.............. Immunodiffusion .................. A................. ........... ........... ........... ........... ...........
ouchterlony.
86332.............. Immune complex assay...... .................. A................. ........... ........... ........... ........... ...........
86334.............. Immunofix e-phoresis, .................. A................. ........... ........... ........... ........... ...........
serum.
86335.............. Immunfix e-phorsis/urine/ .................. A................. ........... ........... ........... ........... ...........
csf.
86336.............. Inhibin A................. .................. A................. ........... ........... ........... ........... ...........
86337.............. Insulin antibodies........ .................. A................. ........... ........... ........... ........... ...........
86340.............. Intrinsic factor antibody. .................. A................. ........... ........... ........... ........... ...........
86341.............. Islet cell antibody....... .................. A................. ........... ........... ........... ........... ...........
86343.............. Leukocyte histamine .................. A................. ........... ........... ........... ........... ...........
release.
86344.............. Leukocyte phagocytosis.... .................. A................. ........... ........... ........... ........... ...........
86353.............. Lymphocyte transformation. .................. A................. ........... ........... ........... ........... ...........
86355.............. B cells, total count...... .................. A................. ........... ........... ........... ........... ...........
86356.............. Mononuclear cell antigen.. NI................ A................. ........... ........... ........... ........... ...........
86357.............. Nk cells, total count..... .................. A................. ........... ........... ........... ........... ...........
86359.............. T cells, total count...... .................. A................. ........... ........... ........... ........... ...........
86360.............. T cell, absolute count/ .................. A................. ........... ........... ........... ........... ...........
ratio.
86361.............. T cell, absolute count.... .................. A................. ........... ........... ........... ........... ...........
86367.............. Stem cells, total count... .................. A................. ........... ........... ........... ........... ...........
86376.............. Microsomal antibody....... .................. A................. ........... ........... ........... ........... ...........
86378.............. Migration inhibitory .................. A................. ........... ........... ........... ........... ...........
factor.
86382.............. Neutralization test, viral .................. A................. ........... ........... ........... ........... ...........
86384.............. Nitroblue tetrazolium dye. .................. A................. ........... ........... ........... ........... ...........
86403.............. Particle agglutination .................. A................. ........... ........... ........... ........... ...........
test.
86406.............. Particle agglutination .................. A................. ........... ........... ........... ........... ...........
test.
86430.............. Rheumatoid factor test.... .................. A................. ........... ........... ........... ........... ...........
86431.............. Rheumatoid factor, quant.. .................. A................. ........... ........... ........... ........... ...........
86480.............. Tb test, cell immun .................. A................. ........... ........... ........... ........... ...........
measure.
86485.............. Skin test, candida........ .................. X................. 0341 0.0844 $5.38 $2.14 $1.08
86486.............. Skin test, nos antigen.... NI................ A................. ........... ........... ........... ........... ...........
86490.............. Coccidioidomycosis skin .................. X................. 0341 0.0844 $5.38 $2.14 $1.08
test.
86510.............. Histoplasmosis skin test.. .................. X................. 0341 0.0844 $5.38 $2.14 $1.08
86580.............. TB intradermal test....... .................. X................. 0341 0.0844 $5.38 $2.14 $1.08
86586.............. Skin test, unlisted....... CH................ D................. ........... ........... ........... ........... ...........
86590.............. Streptokinase, antibody... .................. A................. ........... ........... ........... ........... ...........
86592.............. Blood serology, .................. A................. ........... ........... ........... ........... ...........
qualitative.
86593.............. Blood serology, .................. A................. ........... ........... ........... ........... ...........
quantitative.
86602.............. Antinomyces antibody...... .................. A................. ........... ........... ........... ........... ...........
86603.............. Adenovirus antibody....... .................. A................. ........... ........... ........... ........... ...........
86606.............. Aspergillus antibody...... .................. A................. ........... ........... ........... ........... ...........
86609.............. Bacterium antibody........ .................. A................. ........... ........... ........... ........... ...........
86611.............. Bartonella antibody....... .................. A................. ........... ........... ........... ........... ...........
86612.............. Blastomyces antibody...... .................. A................. ........... ........... ........... ........... ...........
86615.............. Bordetella antibody....... .................. A................. ........... ........... ........... ........... ...........
86617.............. Lyme disease antibody..... .................. A................. ........... ........... ........... ........... ...........
86618.............. Lyme disease antibody..... .................. A................. ........... ........... ........... ........... ...........
86619.............. Borrelia antibody......... .................. A................. ........... ........... ........... ........... ...........
86622.............. Brucella antibody......... .................. A................. ........... ........... ........... ........... ...........
86625.............. Campylobacter antibody.... .................. A................. ........... ........... ........... ........... ...........
86628.............. Candida antibody.......... .................. A................. ........... ........... ........... ........... ...........
86631.............. Chlamydia antibody........ .................. A................. ........... ........... ........... ........... ...........
86632.............. Chlamydia igm antibody.... .................. A................. ........... ........... ........... ........... ...........
86635.............. Coccidioides antibody..... .................. A................. ........... ........... ........... ........... ...........
86638.............. Q fever antibody.......... .................. A................. ........... ........... ........... ........... ...........
86641.............. Cryptococcus antibody..... .................. A................. ........... ........... ........... ........... ...........
86644.............. CMV antibody.............. .................. A................. ........... ........... ........... ........... ...........
86645.............. CMV antibody, IgM......... .................. A................. ........... ........... ........... ........... ...........
86648.............. Diphtheria antibody....... .................. A................. ........... ........... ........... ........... ...........
86651.............. Encephalitis antibody..... .................. A................. ........... ........... ........... ........... ...........
86652.............. Encephalitis antibody..... .................. A................. ........... ........... ........... ........... ...........
86653.............. Encephalitis antibody..... .................. A................. ........... ........... ........... ........... ...........
86654.............. Encephalitis antibody..... .................. A................. ........... ........... ........... ........... ...........
86658.............. Enterovirus antibody...... .................. A................. ........... ........... ........... ........... ...........
86663.............. Epstein-barr antibody..... .................. A................. ........... ........... ........... ........... ...........
86664.............. Epstein-barr antibody..... .................. A................. ........... ........... ........... ........... ...........
86665.............. Epstein-barr antibody..... .................. A................. ........... ........... ........... ........... ...........
86666.............. Ehrlichia antibody........ .................. A................. ........... ........... ........... ........... ...........
86668.............. Francisella tularensis.... .................. A................. ........... ........... ........... ........... ...........
86671.............. Fungus antibody........... .................. A................. ........... ........... ........... ........... ...........
86674.............. Giardia lamblia antibody.. .................. A................. ........... ........... ........... ........... ...........
[[Page 67089]]
86677.............. Helicobacter pylori....... .................. A................. ........... ........... ........... ........... ...........
86682.............. Helminth antibody......... .................. A................. ........... ........... ........... ........... ...........
86684.............. Hemophilus influenza...... .................. A................. ........... ........... ........... ........... ...........
86687.............. Htlv-i antibody........... .................. A................. ........... ........... ........... ........... ...........
86688.............. Htlv-ii antibody.......... .................. A................. ........... ........... ........... ........... ...........
86689.............. HTLV/HIV confirmatory test .................. A................. ........... ........... ........... ........... ...........
86692.............. Hepatitis, delta agent.... .................. A................. ........... ........... ........... ........... ...........
86694.............. Herpes simplex test....... .................. A................. ........... ........... ........... ........... ...........
86695.............. Herpes simplex test....... .................. A................. ........... ........... ........... ........... ...........
86696.............. Herpes simplex type 2..... .................. A................. ........... ........... ........... ........... ...........
86698.............. Histoplasma............... .................. A................. ........... ........... ........... ........... ...........
86701.............. HIV-1..................... .................. A................. ........... ........... ........... ........... ...........
86702.............. HIV-2..................... .................. A................. ........... ........... ........... ........... ...........
86703.............. HIV-1/HIV-2, single assay. .................. A................. ........... ........... ........... ........... ...........
86704.............. Hep b core antibody, total .................. A................. ........... ........... ........... ........... ...........
86705.............. Hep b core antibody, igm.. .................. A................. ........... ........... ........... ........... ...........
86706.............. Hep b surface antibody.... .................. A................. ........... ........... ........... ........... ...........
86707.............. Hep be antibody........... .................. A................. ........... ........... ........... ........... ...........
86708.............. Hep a antibody, total..... .................. A................. ........... ........... ........... ........... ...........
86709.............. Hep a antibody, igm....... .................. A................. ........... ........... ........... ........... ...........
86710.............. Influenza virus antibody.. .................. A................. ........... ........... ........... ........... ...........
86713.............. Legionella antibody....... .................. A................. ........... ........... ........... ........... ...........
86717.............. Leishmania antibody....... .................. A................. ........... ........... ........... ........... ...........
86720.............. Leptospira antibody....... .................. A................. ........... ........... ........... ........... ...........
86723.............. Listeria monocytogenes ab. .................. A................. ........... ........... ........... ........... ...........
86727.............. Lymph choriomeningitis ab. .................. A................. ........... ........... ........... ........... ...........
86729.............. Lympho venereum antibody.. .................. A................. ........... ........... ........... ........... ...........
86732.............. Mucormycosis antibody..... .................. A................. ........... ........... ........... ........... ...........
86735.............. Mumps antibody............ .................. A................. ........... ........... ........... ........... ...........
86738.............. Mycoplasma antibody....... .................. A................. ........... ........... ........... ........... ...........
86741.............. Neisseria meningitidis.... .................. A................. ........... ........... ........... ........... ...........
86744.............. Nocardia antibody......... .................. A................. ........... ........... ........... ........... ...........
86747.............. Parvovirus antibody....... .................. A................. ........... ........... ........... ........... ...........
86750.............. Malaria antibody.......... .................. A................. ........... ........... ........... ........... ...........
86753.............. Protozoa antibody nos..... .................. A................. ........... ........... ........... ........... ...........
86756.............. Respiratory virus antibody .................. A................. ........... ........... ........... ........... ...........
86757.............. Rickettsia antibody....... .................. A................. ........... ........... ........... ........... ...........
86759.............. Rotavirus antibody........ .................. A................. ........... ........... ........... ........... ...........
86762.............. Rubella antibody.......... .................. A................. ........... ........... ........... ........... ...........
86765.............. Rubeola antibody.......... .................. A................. ........... ........... ........... ........... ...........
86768.............. Salmonella antibody....... .................. A................. ........... ........... ........... ........... ...........
86771.............. Shigella antibody......... .................. A................. ........... ........... ........... ........... ...........
86774.............. Tetanus antibody.......... .................. A................. ........... ........... ........... ........... ...........
86777.............. Toxoplasma antibody....... .................. A................. ........... ........... ........... ........... ...........
86778.............. Toxoplasma antibody, igm.. .................. A................. ........... ........... ........... ........... ...........
86781.............. Treponema pallidum, .................. A................. ........... ........... ........... ........... ...........
confirm.
86784.............. Trichinella antibody...... .................. A................. ........... ........... ........... ........... ...........
86787.............. Varicella-zoster antibody. .................. A................. ........... ........... ........... ........... ...........
86788.............. West nile virus ab, igm... .................. A................. ........... ........... ........... ........... ...........
86789.............. West nile virus antibody.. .................. A................. ........... ........... ........... ........... ...........
86790.............. Virus antibody nos........ .................. A................. ........... ........... ........... ........... ...........
86793.............. Yersinia antibody......... .................. A................. ........... ........... ........... ........... ...........
86800.............. Thyroglobulin antibody.... .................. A................. ........... ........... ........... ........... ...........
86803.............. Hepatitis c ab test....... .................. A................. ........... ........... ........... ........... ...........
86804.............. Hep c ab test, confirm.... .................. A................. ........... ........... ........... ........... ...........
86805.............. Lymphocytotoxicity assay.. .................. A................. ........... ........... ........... ........... ...........
86806.............. Lymphocytotoxicity assay.. .................. A................. ........... ........... ........... ........... ...........
86807.............. Cytotoxic antibody .................. A................. ........... ........... ........... ........... ...........
screening.
86808.............. Cytotoxic antibody .................. A................. ........... ........... ........... ........... ...........
screening.
86812.............. HLA typing, A, B, or C.... .................. A................. ........... ........... ........... ........... ...........
86813.............. HLA typing, A, B, or C.... .................. A................. ........... ........... ........... ........... ...........
86816.............. HLA typing, DR/DQ......... .................. A................. ........... ........... ........... ........... ...........
86817.............. HLA typing, DR/DQ......... .................. A................. ........... ........... ........... ........... ...........
86821.............. Lymphocyte culture, mixed. .................. A................. ........... ........... ........... ........... ...........
86822.............. Lymphocyte culture, primed .................. A................. ........... ........... ........... ........... ...........
86849.............. Immunology procedure...... .................. A................. ........... ........... ........... ........... ...........
86850.............. RBC antibody screen....... .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
86860.............. RBC antibody elution...... .................. X................. 0346 0.3346 $21.31 $4.37 $4.26
86870.............. RBC antibody .................. X................. 0346 0.3346 $21.31 $4.37 $4.26
identification.
86880.............. Coombs test, direct....... .................. X................. 0409 0.1190 $7.58 $2.20 $1.52
86885.............. Coombs test, indirect, .................. X................. 0409 0.1190 $7.58 $2.20 $1.52
qual.
86886.............. Coombs test, indirect, .................. X................. 0409 0.1190 $7.58 $2.20 $1.52
titer.
86890.............. Autologous blood process.. .................. X................. 0347 0.7739 $49.29 $11.28 $9.86
86891.............. Autologous blood, op .................. X................. 0346 0.3346 $21.31 $4.37 $4.26
salvage.
86900.............. Blood typing, ABO......... .................. X................. 0409 0.1190 $7.58 $2.20 $1.52
86901.............. Blood typing, Rh (D)...... .................. X................. 0409 0.1190 $7.58 $2.20 $1.52
86903.............. Blood typing, antigen .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
screen.
86904.............. Blood typing, patient .................. X................. 0346 0.3346 $21.31 $4.37 $4.26
serum.
86905.............. Blood typing, RBC antigens .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
86906.............. Blood typing, Rh phenotype .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
[[Page 67090]]
86910.............. Blood typing, paternity .................. E................. ........... ........... ........... ........... ...........
test.
86911.............. Blood typing, antigen .................. E................. ........... ........... ........... ........... ...........
system.
86920.............. Compatibility test, spin.. .................. X................. 0346 0.3346 $21.31 $4.37 $4.26
86921.............. Compatibility test, .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
incubate.
86922.............. Compatibility test, .................. X................. 0346 0.3346 $21.31 $4.37 $4.26
antiglob.
86923.............. Compatibility test, .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
electric.
86927.............. Plasma, fresh frozen...... .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
86930.............. Frozen blood prep......... .................. X................. 0347 0.7739 $49.29 $11.28 $9.86
86931.............. Frozen blood thaw......... .................. X................. 0347 0.7739 $49.29 $11.28 $9.86
86932.............. Frozen blood freeze/thaw.. .................. X................. 0347 0.7739 $49.29 $11.28 $9.86
86940.............. Hemolysins/agglutinins, .................. A................. ........... ........... ........... ........... ...........
auto.
86941.............. Hemolysins/agglutinins.... .................. A................. ........... ........... ........... ........... ...........
86945.............. Blood product/irradiation. .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
86950.............. Leukacyte transfusion..... .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
86960.............. Vol reduction of blood/ .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
prod.
86965.............. Pooling blood platelets... .................. X................. 0346 0.3346 $21.31 $4.37 $4.26
86970.............. RBC pretreatment.......... .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
86971.............. RBC pretreatment.......... .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
86972.............. RBC pretreatment.......... .................. X................. 0346 0.3346 $21.31 $4.37 $4.26
86975.............. RBC pretreatment, serum... .................. X................. 0346 0.3346 $21.31 $4.37 $4.26
86976.............. RBC pretreatment, serum... .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
86977.............. RBC pretreatment, serum... .................. X................. 0346 0.3346 $21.31 $4.37 $4.26
86978.............. RBC pretreatment, serum... .................. X................. 0346 0.3346 $21.31 $4.37 $4.26
86985.............. Split blood or products... .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
86999.............. Transfusion procedure..... .................. X................. 0345 0.2140 $13.63 $2.87 $2.73
87001.............. Small animal inoculation.. .................. A................. ........... ........... ........... ........... ...........
87003.............. Small animal inoculation.. .................. A................. ........... ........... ........... ........... ...........
87015.............. Specimen concentration.... .................. A................. ........... ........... ........... ........... ...........
87040.............. Blood culture for bacteria .................. A................. ........... ........... ........... ........... ...........
87045.............. Feces culture, bacteria... .................. A................. ........... ........... ........... ........... ...........
87046.............. Stool cultr, bacteria, .................. A................. ........... ........... ........... ........... ...........
each.
87070.............. Culture, bacteria, other.. .................. A................. ........... ........... ........... ........... ...........
87071.............. Culture bacteri aerobic .................. A................. ........... ........... ........... ........... ...........
othr.
87073.............. Culture bacteria anaerobic .................. A................. ........... ........... ........... ........... ...........
87075.............. Cultr bacteria, except .................. A................. ........... ........... ........... ........... ...........
blood.
87076.............. Culture anaerobe ident, .................. A................. ........... ........... ........... ........... ...........
each.
87077.............. Culture aerobic identify.. .................. A................. ........... ........... ........... ........... ...........
87081.............. Culture screen only....... .................. A................. ........... ........... ........... ........... ...........
87084.............. Culture of specimen by kit .................. A................. ........... ........... ........... ........... ...........
87086.............. Urine culture/colony count .................. A................. ........... ........... ........... ........... ...........
87088.............. Urine bacteria culture.... .................. A................. ........... ........... ........... ........... ...........
87101.............. Skin fungi culture........ .................. A................. ........... ........... ........... ........... ...........
87102.............. Fungus isolation culture.. .................. A................. ........... ........... ........... ........... ...........
87103.............. Blood fungus culture...... .................. A................. ........... ........... ........... ........... ...........
87106.............. Fungi identification, .................. A................. ........... ........... ........... ........... ...........
yeast.
87107.............. Fungi identification, mold .................. A................. ........... ........... ........... ........... ...........
87109.............. Mycoplasma................ .................. A................. ........... ........... ........... ........... ...........
87110.............. Chlamydia culture......... .................. A................. ........... ........... ........... ........... ...........
87116.............. Mycobacteria culture...... .................. A................. ........... ........... ........... ........... ...........
87118.............. Mycobacteric .................. A................. ........... ........... ........... ........... ...........
identification.
87140.............. Culture type .................. A................. ........... ........... ........... ........... ...........
immunofluoresc.
87143.............. Culture typing, glc/hplc.. .................. A................. ........... ........... ........... ........... ...........
87147.............. Culture type, immunologic. .................. A................. ........... ........... ........... ........... ...........
87149.............. Culture type, nucleic acid .................. A................. ........... ........... ........... ........... ...........
87152.............. Culture type pulse field .................. A................. ........... ........... ........... ........... ...........
gel.
87158.............. Culture typing, added .................. A................. ........... ........... ........... ........... ...........
method.
87164.............. Dark field examination.... .................. A................. ........... ........... ........... ........... ...........
87166.............. Dark field examination.... .................. A................. ........... ........... ........... ........... ...........
87168.............. Macroscopic exam arthropod .................. A................. ........... ........... ........... ........... ...........
87169.............. Macroscopic exam parasite. .................. A................. ........... ........... ........... ........... ...........
87172.............. Pinworm exam.............. .................. A................. ........... ........... ........... ........... ...........
87176.............. Tissue homogenization, .................. A................. ........... ........... ........... ........... ...........
cultr.
87177.............. Ova and parasites smears.. .................. A................. ........... ........... ........... ........... ...........
87181.............. Microbe susceptible, .................. A................. ........... ........... ........... ........... ...........
diffuse.
87184.............. Microbe susceptible, disk. .................. A................. ........... ........... ........... ........... ...........
87185.............. Microbe susceptible, .................. A................. ........... ........... ........... ........... ...........
enzyme.
87186.............. Microbe susceptible, mic.. .................. A................. ........... ........... ........... ........... ...........
87187.............. Microbe susceptible, mlc.. .................. A................. ........... ........... ........... ........... ...........
87188.............. Microbe suscept, .................. A................. ........... ........... ........... ........... ...........
macrobroth.
87190.............. Microbe suscept, .................. A................. ........... ........... ........... ........... ...........
mycobacteri.
87197.............. Bactericidal level, serum. .................. A................. ........... ........... ........... ........... ...........
87205.............. Smear, gram stain......... .................. A................. ........... ........... ........... ........... ...........
87206.............. Smear, fluorescent/acid .................. A................. ........... ........... ........... ........... ...........
stai.
87207.............. Smear, special stain...... .................. A................. ........... ........... ........... ........... ...........
87209.............. Smear, complex stain...... .................. A................. ........... ........... ........... ........... ...........
87210.............. Smear, wet mount, saline/ .................. A................. ........... ........... ........... ........... ...........
ink.
87220.............. Tissue exam for fungi..... .................. A................. ........... ........... ........... ........... ...........
87230.............. Assay, toxin or antitoxin. .................. A................. ........... ........... ........... ........... ...........
87250.............. Virus inoculate, eggs/ .................. A................. ........... ........... ........... ........... ...........
animal.
87252.............. Virus inoculation, tissue. .................. A................. ........... ........... ........... ........... ...........
[[Page 67091]]
87253.............. Virus inoculate tissue, .................. A................. ........... ........... ........... ........... ...........
addl.
87254.............. Virus inoculation, shell .................. A................. ........... ........... ........... ........... ...........
via.
87255.............. Genet virus isolate, hsv.. .................. A................. ........... ........... ........... ........... ...........
87260.............. Adenovirus ag, if......... .................. A................. ........... ........... ........... ........... ...........
87265.............. Pertussis ag, if.......... .................. A................. ........... ........... ........... ........... ...........
87267.............. Enterovirus antibody, dfa. .................. A................. ........... ........... ........... ........... ...........
87269.............. Giardia ag, if............ .................. A................. ........... ........... ........... ........... ...........
87270.............. Chlamydia trachomatis ag, .................. A................. ........... ........... ........... ........... ...........
if.
87271.............. Cytomegalovirus dfa....... .................. A................. ........... ........... ........... ........... ...........
87272.............. Cryptosporidium ag, if.... .................. A................. ........... ........... ........... ........... ...........
87273.............. Herpes simplex 2, ag, if.. .................. A................. ........... ........... ........... ........... ...........
87274.............. Herpes simplex 1, ag, if.. .................. A................. ........... ........... ........... ........... ...........
87275.............. Influenza b, ag, if....... .................. A................. ........... ........... ........... ........... ...........
87276.............. Influenza a, ag, if....... .................. A................. ........... ........... ........... ........... ...........
87277.............. Legionella micdadei, ag, .................. A................. ........... ........... ........... ........... ...........
if.
87278.............. Legion pneumophilia ag, if .................. A................. ........... ........... ........... ........... ...........
87279.............. Parainfluenza, ag, if..... .................. A................. ........... ........... ........... ........... ...........
87280.............. Respiratory syncytial ag, .................. A................. ........... ........... ........... ........... ...........
if.
87281.............. Pneumocystis carinii, ag, .................. A................. ........... ........... ........... ........... ...........
if.
87283.............. Rubeola, ag, if........... .................. A................. ........... ........... ........... ........... ...........
87285.............. Treponema pallidum, ag, if .................. A................. ........... ........... ........... ........... ...........
87290.............. Varicella zoster, ag, if.. .................. A................. ........... ........... ........... ........... ...........
87299.............. Antibody detection, nos, .................. A................. ........... ........... ........... ........... ...........
if.
87300.............. Ag detection, polyval, if. .................. A................. ........... ........... ........... ........... ...........
87301.............. Adenovirus ag, eia........ .................. A................. ........... ........... ........... ........... ...........
87305.............. Aspergillus ag, eia....... .................. A................. ........... ........... ........... ........... ...........
87320.............. Chylmd trach ag, eia...... .................. A................. ........... ........... ........... ........... ...........
87324.............. Clostridium ag, eia....... .................. A................. ........... ........... ........... ........... ...........
87327.............. Cryptococcus neoform ag, .................. A................. ........... ........... ........... ........... ...........
eia.
87328.............. Cryptosporidium ag, eia... .................. A................. ........... ........... ........... ........... ...........
87329.............. Giardia ag, eia........... .................. A................. ........... ........... ........... ........... ...........
87332.............. Cytomegalovirus ag, eia... .................. A................. ........... ........... ........... ........... ...........
87335.............. E coli 0157 ag, eia....... .................. A................. ........... ........... ........... ........... ...........
87336.............. Entamoeb hist dispr, ag, .................. A................. ........... ........... ........... ........... ...........
eia.
87337.............. Entamoeb hist group, ag, .................. A................. ........... ........... ........... ........... ...........
eia.
87338.............. Hpylori, stool, eia....... .................. A................. ........... ........... ........... ........... ...........
87339.............. H pylori ag, eia.......... .................. A................. ........... ........... ........... ........... ...........
87340.............. Hepatitis b surface ag, .................. A................. ........... ........... ........... ........... ...........
eia.
87341.............. Hepatitis b surface, ag, .................. A................. ........... ........... ........... ........... ...........
eia.
87350.............. Hepatitis be ag, eia...... .................. A................. ........... ........... ........... ........... ...........
87380.............. Hepatitis delta ag, eia... .................. A................. ........... ........... ........... ........... ...........
87385.............. Histoplasma capsul ag, eia .................. A................. ........... ........... ........... ........... ...........
87390.............. Hiv-1 ag, eia............. .................. A................. ........... ........... ........... ........... ...........
87391.............. Hiv-2 ag, eia............. .................. A................. ........... ........... ........... ........... ...........
87400.............. Influenza a/b, ag, eia.... .................. A................. ........... ........... ........... ........... ...........
87420.............. Resp syncytial ag, eia.... .................. A................. ........... ........... ........... ........... ...........
87425.............. Rotavirus ag, eia......... .................. A................. ........... ........... ........... ........... ...........
87427.............. Shiga-like toxin ag, eia.. .................. A................. ........... ........... ........... ........... ...........
87430.............. Strep a ag, eia........... .................. A................. ........... ........... ........... ........... ...........
87449.............. Ag detect nos, eia, mult.. .................. A................. ........... ........... ........... ........... ...........
87450.............. Ag detect nos, eia, single .................. A................. ........... ........... ........... ........... ...........
87451.............. Ag detect polyval, eia, .................. A................. ........... ........... ........... ........... ...........
mult.
87470.............. Bartonella, dna, dir probe .................. A................. ........... ........... ........... ........... ...........
87471.............. Bartonella, dna, amp probe .................. A................. ........... ........... ........... ........... ...........
87472.............. Bartonella, dna, quant.... .................. A................. ........... ........... ........... ........... ...........
87475.............. Lyme dis, dna, dir probe.. .................. A................. ........... ........... ........... ........... ...........
87476.............. Lyme dis, dna, amp probe.. .................. A................. ........... ........... ........... ........... ...........
87477.............. Lyme dis, dna, quant...... .................. A................. ........... ........... ........... ........... ...........
87480.............. Candida, dna, dir probe... .................. A................. ........... ........... ........... ........... ...........
87481.............. Candida, dna, amp probe... .................. A................. ........... ........... ........... ........... ...........
87482.............. Candida, dna, quant....... .................. A................. ........... ........... ........... ........... ...........
87485.............. Chylmd pneum, dna, dir .................. A................. ........... ........... ........... ........... ...........
probe.
87486.............. Chylmd pneum, dna, amp .................. A................. ........... ........... ........... ........... ...........
probe.
87487.............. Chylmd pneum, dna, quant.. .................. A................. ........... ........... ........... ........... ...........
87490.............. Chylmd trach, dna, dir .................. A................. ........... ........... ........... ........... ...........
probe.
87491.............. Chylmd trach, dna, amp .................. A................. ........... ........... ........... ........... ...........
probe.
87492.............. Chylmd trach, dna, quant.. .................. A................. ........... ........... ........... ........... ...........
87495.............. Cytomeg, dna, dir probe... .................. A................. ........... ........... ........... ........... ...........
87496.............. Cytomeg, dna, amp probe... .................. A................. ........... ........... ........... ........... ...........
87497.............. Cytomeg, dna, quant....... .................. A................. ........... ........... ........... ........... ...........
87498.............. Enterovirus, dna, amp .................. A................. ........... ........... ........... ........... ...........
probe.
87500.............. Vanomycin, dna, amp probe. NI................ A................. ........... ........... ........... ........... ...........
87510.............. Gardner vag, dna, dir .................. A................. ........... ........... ........... ........... ...........
probe.
87511.............. Gardner vag, dna, amp .................. A................. ........... ........... ........... ........... ...........
probe.
87512.............. Gardner vag, dna, quant... .................. A................. ........... ........... ........... ........... ...........
87515.............. Hepatitis b, dna, dir .................. A................. ........... ........... ........... ........... ...........
probe.
87516.............. Hepatitis b, dna, amp .................. A................. ........... ........... ........... ........... ...........
probe.
87517.............. Hepatitis b, dna, quant... .................. A................. ........... ........... ........... ........... ...........
87520.............. Hepatitis c, rna, dir .................. A................. ........... ........... ........... ........... ...........
probe.
87521.............. Hepatitis c, rna, amp .................. A................. ........... ........... ........... ........... ...........
probe.
[[Page 67092]]
87522.............. Hepatitis c, rna, quant... .................. A................. ........... ........... ........... ........... ...........
87525.............. Hepatitis g, dna, dir .................. A................. ........... ........... ........... ........... ...........
probe.
87526.............. Hepatitis g, dna, amp .................. A................. ........... ........... ........... ........... ...........
probe.
87527.............. Hepatitis g, dna, quant... .................. A................. ........... ........... ........... ........... ...........
87528.............. Hsv, dna, dir probe....... .................. A................. ........... ........... ........... ........... ...........
87529.............. Hsv, dna, amp probe....... .................. A................. ........... ........... ........... ........... ...........
87530.............. Hsv, dna, quant........... .................. A................. ........... ........... ........... ........... ...........
87531.............. Hhv-6, dna, dir probe..... .................. A................. ........... ........... ........... ........... ...........
87532.............. Hhv-6, dna, amp probe..... .................. A................. ........... ........... ........... ........... ...........
87533.............. Hhv-6, dna, quant......... .................. A................. ........... ........... ........... ........... ...........
87534.............. Hiv-1, dna, dir probe..... .................. A................. ........... ........... ........... ........... ...........
87535.............. Hiv-1, dna, amp probe..... .................. A................. ........... ........... ........... ........... ...........
87536.............. Hiv-1, dna, quant......... .................. A................. ........... ........... ........... ........... ...........
87537.............. Hiv-2, dna, dir probe..... .................. A................. ........... ........... ........... ........... ...........
87538.............. Hiv-2, dna, amp probe..... .................. A................. ........... ........... ........... ........... ...........
87539.............. Hiv-2, dna, quant......... .................. A................. ........... ........... ........... ........... ...........
87540.............. Legion pneumo, dna, dir .................. A................. ........... ........... ........... ........... ...........
prob.
87541.............. Legion pneumo, dna, amp .................. A................. ........... ........... ........... ........... ...........
prob.
87542.............. Legion pneumo, dna, quant. .................. A................. ........... ........... ........... ........... ...........
87550.............. Mycobacteria, dna, dir .................. A................. ........... ........... ........... ........... ...........
probe.
87551.............. Mycobacteria, dna, amp .................. A................. ........... ........... ........... ........... ...........
probe.
87552.............. Mycobacteria, dna, quant.. .................. A................. ........... ........... ........... ........... ...........
87555.............. M.tuberculo, dna, dir .................. A................. ........... ........... ........... ........... ...........
probe.
87556.............. M.tuberculo, dna, amp .................. A................. ........... ........... ........... ........... ...........
probe.
87557.............. M.tuberculo, dna, quant... .................. A................. ........... ........... ........... ........... ...........
87560.............. M.avium-intra, dna, dir .................. A................. ........... ........... ........... ........... ...........
prob.
87561.............. M.avium-intra, dna, amp .................. A................. ........... ........... ........... ........... ...........
prob.
87562.............. M.avium-intra, dna, quant. .................. A................. ........... ........... ........... ........... ...........
87580.............. M.pneumon, dna, dir probe. .................. A................. ........... ........... ........... ........... ...........
87581.............. M.pneumon, dna, amp probe. .................. A................. ........... ........... ........... ........... ...........
87582.............. M.pneumon, dna, quant..... .................. A................. ........... ........... ........... ........... ...........
87590.............. N.gonorrhoeae, dna, dir .................. A................. ........... ........... ........... ........... ...........
prob.
87591.............. N.gonorrhoeae, dna, amp .................. A................. ........... ........... ........... ........... ...........
prob.
87592.............. N.gonorrhoeae, dna, quant. .................. A................. ........... ........... ........... ........... ...........
87620.............. Hpv, dna, dir probe....... .................. A................. ........... ........... ........... ........... ...........
87621.............. Hpv, dna, amp probe....... .................. A................. ........... ........... ........... ........... ...........
87622.............. Hpv, dna, quant........... .................. A................. ........... ........... ........... ........... ...........
87640.............. Staph a, dna, amp probe... .................. A................. ........... ........... ........... ........... ...........
87641.............. Mr-staph, dna, amp probe.. .................. A................. ........... ........... ........... ........... ...........
87650.............. Strep a, dna, dir probe... .................. A................. ........... ........... ........... ........... ...........
87651.............. Strep a, dna, amp probe... .................. A................. ........... ........... ........... ........... ...........
87652.............. Strep a, dna, quant....... .................. A................. ........... ........... ........... ........... ...........
87653.............. Strep b, dna, amp probe... .................. A................. ........... ........... ........... ........... ...........
87660.............. Trichomonas vagin, dir .................. A................. ........... ........... ........... ........... ...........
probe.
87797.............. Detect agent nos, dna, dir .................. A................. ........... ........... ........... ........... ...........
87798.............. Detect agent nos, dna, amp .................. A................. ........... ........... ........... ........... ...........
87799.............. Detect agent nos, dna, .................. A................. ........... ........... ........... ........... ...........
quant.
87800.............. Detect agnt mult, dna, .................. A................. ........... ........... ........... ........... ...........
direc.
87801.............. Detect agnt mult, dna, .................. A................. ........... ........... ........... ........... ...........
ampli.
87802.............. Strep b assay w/optic..... .................. A................. ........... ........... ........... ........... ...........
87803.............. Clostridium toxin a w/ .................. A................. ........... ........... ........... ........... ...........
optic.
87804.............. Influenza assay w/optic... .................. A................. ........... ........... ........... ........... ...........
87807.............. Rsv assay w/optic......... .................. A................. ........... ........... ........... ........... ...........
87808.............. Trichomonas assay w/optic. .................. A................. ........... ........... ........... ........... ...........
87809.............. Adenovirus assay w/optic.. NI................ A................. ........... ........... ........... ........... ...........
87810.............. Chylmd trach assay w/optic .................. A................. ........... ........... ........... ........... ...........
87850.............. N. gonorrhoeae assay w/ .................. A................. ........... ........... ........... ........... ...........
optic.
87880.............. Strep a assay w/optic..... .................. A................. ........... ........... ........... ........... ...........
87899.............. Agent nos assay w/optic... .................. A................. ........... ........... ........... ........... ...........
87900.............. Phenotype, infect agent .................. A................. ........... ........... ........... ........... ...........
drug.
87901.............. Genotype, dna, hiv reverse .................. A................. ........... ........... ........... ........... ...........
t.
87902.............. Genotype, dna, hepatitis C .................. A................. ........... ........... ........... ........... ...........
87903.............. Phenotype, dna hiv w/ .................. A................. ........... ........... ........... ........... ...........
culture.
87904.............. Phenotype, dna hiv w/clt .................. A................. ........... ........... ........... ........... ...........
add.
87999.............. Microbiology procedure.... .................. A................. ........... ........... ........... ........... ...........
88000.............. Autopsy (necropsy), gross. .................. E................. ........... ........... ........... ........... ...........
88005.............. Autopsy (necropsy), gross. .................. E................. ........... ........... ........... ........... ...........
88007.............. Autopsy (necropsy), gross. .................. E................. ........... ........... ........... ........... ...........
88012.............. Autopsy (necropsy), gross. .................. E................. ........... ........... ........... ........... ...........
88014.............. Autopsy (necropsy), gross. .................. E................. ........... ........... ........... ........... ...........
88016.............. Autopsy (necropsy), gross. .................. E................. ........... ........... ........... ........... ...........
88020.............. Autopsy (necropsy), .................. E................. ........... ........... ........... ........... ...........
complete.
88025.............. Autopsy (necropsy), .................. E................. ........... ........... ........... ........... ...........
complete.
88027.............. Autopsy (necropsy), .................. E................. ........... ........... ........... ........... ...........
complete.
88028.............. Autopsy (necropsy), .................. E................. ........... ........... ........... ........... ...........
complete.
88029.............. Autopsy (necropsy), .................. E................. ........... ........... ........... ........... ...........
complete.
88036.............. Limited autopsy........... .................. E................. ........... ........... ........... ........... ...........
88037.............. Limited autopsy........... .................. E................. ........... ........... ........... ........... ...........
88040.............. Forensic autopsy .................. E................. ........... ........... ........... ........... ...........
(necropsy).
88045.............. Coroner's autopsy .................. E................. ........... ........... ........... ........... ...........
(necropsy).
[[Page 67093]]
88099.............. Necropsy (autopsy) .................. E................. ........... ........... ........... ........... ...........
procedure.
88104.............. Cytopath fl nongyn, smears .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88106.............. Cytopath fl nongyn, filter .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88107.............. Cytopath fl nongyn, sm/ CH................ X................. 0343 0.5142 $32.75 $10.84 $6.55
fltr.
88108.............. Cytopath, concentrate tech CH................ X................. 0343 0.5142 $32.75 $10.84 $6.55
88112.............. Cytopath, cell enhance .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
tech.
88125.............. Forensic cytopathology.... .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88130.............. Sex chromatin .................. A................. ........... ........... ........... ........... ...........
identification.
88140.............. Sex chromatin .................. A................. ........... ........... ........... ........... ...........
identification.
88141.............. Cytopath, c/v, interpret.. .................. N................. ........... ........... ........... ........... ...........
88142.............. Cytopath, c/v, thin layer. .................. A................. ........... ........... ........... ........... ...........
88143.............. Cytopath c/v thin layer .................. A................. ........... ........... ........... ........... ...........
redo.
88147.............. Cytopath, c/v, automated.. .................. A................. ........... ........... ........... ........... ...........
88148.............. Cytopath, c/v, auto .................. A................. ........... ........... ........... ........... ...........
rescreen.
88150.............. Cytopath, c/v, manual..... .................. A................. ........... ........... ........... ........... ...........
88152.............. Cytopath, c/v, auto redo.. .................. A................. ........... ........... ........... ........... ...........
88153.............. Cytopath, c/v, redo....... .................. A................. ........... ........... ........... ........... ...........
88154.............. Cytopath, c/v, select..... .................. A................. ........... ........... ........... ........... ...........
88155.............. Cytopath, c/v, index add- .................. A................. ........... ........... ........... ........... ...........
on.
88160.............. Cytopath smear, other .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
source.
88161.............. Cytopath smear, other .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
source.
88162.............. Cytopath smear, other CH................ X................. 0343 0.5142 $32.75 $10.84 $6.55
source.
88164.............. Cytopath tbs, c/v, manual. .................. A................. ........... ........... ........... ........... ...........
88165.............. Cytopath tbs, c/v, redo... .................. A................. ........... ........... ........... ........... ...........
88166.............. Cytopath tbs, c/v, auto .................. A................. ........... ........... ........... ........... ...........
redo.
88167.............. Cytopath tbs, c/v, select. .................. A................. ........... ........... ........... ........... ...........
88172.............. Cytopathology eval of fna. .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
88173.............. Cytopath eval, fna, report .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
88174.............. Cytopath, c/v auto, in .................. A................. ........... ........... ........... ........... ...........
fluid.
88175.............. Cytopath c/v auto fluid .................. A................. ........... ........... ........... ........... ...........
redo.
88182.............. Cell marker study......... .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
88184.............. Flowcytometry/ tc, 1 .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
marker.
88185.............. Flowcytometry/tc, add-on.. .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88187.............. Flowcytometry/read, 2-8... .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88188.............. Flowcytometry/read, 9-15.. .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88189.............. Flowcytometry/read, 16 & > .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
88199.............. Cytopathology procedure... .................. X................. 0342 0.0969 $6.17 $2.02 $1.23
88230.............. Tissue culture, lymphocyte .................. A................. ........... ........... ........... ........... ...........
88233.............. Tissue culture, skin/ .................. A................. ........... ........... ........... ........... ...........
biopsy.
88235.............. Tissue culture, placenta.. .................. A................. ........... ........... ........... ........... ...........
88237.............. Tissue culture, bone .................. A................. ........... ........... ........... ........... ...........
marrow.
88239.............. Tissue culture, tumor..... .................. A................. ........... ........... ........... ........... ...........
88240.............. Cell cryopreserve/storage. .................. A................. ........... ........... ........... ........... ...........
88241.............. Frozen cell preparation... .................. A................. ........... ........... ........... ........... ...........
88245.............. Chromosome analysis, 20-25 .................. A................. ........... ........... ........... ........... ...........
88248.............. Chromosome analysis, 50- .................. A................. ........... ........... ........... ........... ...........
100.
88249.............. Chromosome analysis, 100.. .................. A................. ........... ........... ........... ........... ...........
88261.............. Chromosome analysis, 5.... .................. A................. ........... ........... ........... ........... ...........
88262.............. Chromosome analysis, 15-20 .................. A................. ........... ........... ........... ........... ...........
88263.............. Chromosome analysis, 45... .................. A................. ........... ........... ........... ........... ...........
88264.............. Chromosome analysis, 20-25 .................. A................. ........... ........... ........... ........... ...........
88267.............. Chromosome analys, .................. A................. ........... ........... ........... ........... ...........
placenta.
88269.............. Chromosome analys, .................. A................. ........... ........... ........... ........... ...........
amniotic.
88271.............. Cytogenetics, dna probe... .................. A................. ........... ........... ........... ........... ...........
88272.............. Cytogenetics, 3-5......... .................. A................. ........... ........... ........... ........... ...........
88273.............. Cytogenetics, 10-30....... .................. A................. ........... ........... ........... ........... ...........
88274.............. Cytogenetics, 25-99....... .................. A................. ........... ........... ........... ........... ...........
88275.............. Cytogenetics, 100-300..... .................. A................. ........... ........... ........... ........... ...........
88280.............. Chromosome karyotype study .................. A................. ........... ........... ........... ........... ...........
88283.............. Chromosome banding study.. .................. A................. ........... ........... ........... ........... ...........
88285.............. Chromosome count, .................. A................. ........... ........... ........... ........... ...........
additional.
88289.............. Chromosome study, .................. A................. ........... ........... ........... ........... ...........
additional.
88291.............. Cyto/molecular report..... .................. M................. ........... ........... ........... ........... ...........
88299.............. Cytogenetic study......... .................. X................. 0342 0.0969 $6.17 $2.02 $1.23
88300.............. Surgical path, gross...... .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88302.............. Tissue exam by pathologist .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88304.............. Tissue exam by pathologist .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
88305.............. Tissue exam by pathologist .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
88307.............. Tissue exam by pathologist .................. X................. 0344 0.8167 $52.02 $15.66 $10.40
88309.............. Tissue exam by pathologist .................. X................. 0344 0.8167 $52.02 $15.66 $10.40
88311.............. Decalcify tissue.......... .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88312.............. Special stains............ .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88313.............. Special stains............ .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88314.............. Histochemical stain....... CH................ X................. 0433 0.2397 $15.27 $5.17 $3.05
88318.............. Chemical histochemistry... .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88319.............. Enzyme histochemistry..... CH................ X................. 0433 0.2397 $15.27 $5.17 $3.05
88321.............. Microslide consultation... .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
88323.............. Microslide consultation... .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
88325.............. Comprehensive review of .................. X................. 0344 0.8167 $52.02 $15.66 $10.40
data.
88329.............. Path consult introp....... .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
[[Page 67094]]
88331.............. Path consult intraop, 1 .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
bloc.
88332.............. Path consult intraop, .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
add'l.
88333.............. Intraop cyto path consult, .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
1.
88334.............. Intraop cyto path consult, .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
2.
88342.............. Immunohistochemistry...... .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
88346.............. Immunofluorescent study... .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
88347.............. Immunofluorescent study... .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
88348.............. Electron microscopy....... .................. X................. 0661 2.6949 $171.65 $62.09 $34.33
88349.............. Scanning electron .................. X................. 0661 2.6949 $171.65 $62.09 $34.33
microscopy.
88355.............. Analysis, skeletal muscle. .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
88356.............. Analysis, nerve........... .................. X................. 0344 0.8167 $52.02 $15.66 $10.40
88358.............. Analysis, tumor........... .................. X................. 0344 0.8167 $52.02 $15.66 $10.40
88360.............. Tumor immunohistochem/ .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
manual.
88361.............. Tumor immunohistochem/ .................. X................. 0344 0.8167 $52.02 $15.66 $10.40
comput.
88362.............. Nerve teasing preparations .................. X................. 0344 0.8167 $52.02 $15.66 $10.40
88365.............. Insitu hybridization .................. X................. 0344 0.8167 $52.02 $15.66 $10.40
(fish).
88367.............. Insitu hybridization, auto .................. X................. 0344 0.8167 $52.02 $15.66 $10.40
88368.............. Insitu hybridization, CH................ X................. 0343 0.5142 $32.75 $10.84 $6.55
manual.
88371.............. Protein, western blot .................. A................. ........... ........... ........... ........... ...........
tissue.
88372.............. Protein analysis w/probe.. .................. A................. ........... ........... ........... ........... ...........
88380.............. Microdissection, laser.... .................. N................. ........... ........... ........... ........... ...........
88381.............. Microdissection, manual... NI................ N................. ........... ........... ........... ........... ...........
88384.............. Eval molecular probes, 11- .................. X................. 0433 0.2397 $15.27 $5.17 $3.05
50.
88385.............. Eval molecul probes, 51- .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
250.
88386.............. Eval molecul probes, 251- .................. X................. 0344 0.8167 $52.02 $15.66 $10.40
500.
88399.............. Surgical pathology .................. X................. 0342 0.0969 $6.17 $2.02 $1.23
procedure.
88400.............. Bilirubin total transcut.. .................. A................. ........... ........... ........... ........... ...........
89049.............. Chct for mal hyperthermia. .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
89050.............. Body fluid cell count..... .................. A................. ........... ........... ........... ........... ...........
89051.............. Body fluid cell count..... .................. A................. ........... ........... ........... ........... ...........
89055.............. Leukocyte assessment, .................. A................. ........... ........... ........... ........... ...........
fecal.
89060.............. Exam,synovial fluid .................. A................. ........... ........... ........... ........... ...........
crystals.
89100.............. Sample intestinal contents .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
89105.............. Sample intestinal contents .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
89125.............. Specimen fat stain........ .................. A................. ........... ........... ........... ........... ...........
89130.............. Sample stomach contents... .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
89132.............. Sample stomach contents... .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
89135.............. Sample stomach contents... .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
89136.............. Sample stomach contents... .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
89140.............. Sample stomach contents... .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
89141.............. Sample stomach contents... .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
89160.............. Exam feces for meat fibers .................. A................. ........... ........... ........... ........... ...........
89190.............. Nasal smear for .................. A................. ........... ........... ........... ........... ...........
eosinophils.
89220.............. Sputum specimen collection .................. X................. 0343 0.5142 $32.75 $10.84 $6.55
89225.............. Starch granules, feces.... .................. A................. ........... ........... ........... ........... ...........
89230.............. Collect sweat for test.... CH................ X................. 0343 0.5142 $32.75 $10.84 $6.55
89235.............. Water load test........... .................. A................. ........... ........... ........... ........... ...........
89240.............. Pathology lab procedure... .................. X................. 0342 0.0969 $6.17 $2.02 $1.23
89250.............. Cultr oocyte/embryo <4 CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
days.
89251.............. Cultr oocyte/embryo <4 CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
days.
89253.............. Embryo hatching........... CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89254.............. Oocyte identification..... CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89255.............. Prepare embryo for CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
transfer.
89257.............. Sperm identification...... CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89258.............. Cryopreservation; CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
embryo(s).
89259.............. Cryopreservation, sperm... CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89260.............. Sperm isolation, simple... CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89261.............. Sperm isolation, complex.. CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89264.............. Identify sperm tissue..... CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89268.............. Insemination of oocytes... CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89272.............. Extended culture of CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
oocytes.
89280.............. Assist oocyte CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
fertilization.
89281.............. Assist oocyte CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
fertilization.
89290.............. Biopsy, oocyte polar body. CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89291.............. Biopsy, oocyte polar body. CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89300.............. Semen analysis w/huhner... .................. A................. ........... ........... ........... ........... ...........
89310.............. Semen analysis w/count.... .................. A................. ........... ........... ........... ........... ...........
89320.............. Semen anal vol/count/mot.. .................. A................. ........... ........... ........... ........... ...........
89321.............. Semen anal, sperm .................. A................. ........... ........... ........... ........... ...........
detection.
89322.............. Semen anal, strict NI................ A................. ........... ........... ........... ........... ...........
criteria.
89325.............. Sperm antibody test....... .................. A................. ........... ........... ........... ........... ...........
89329.............. Sperm evaluation test..... .................. A................. ........... ........... ........... ........... ...........
89330.............. Evaluation, cervical mucus .................. A................. ........... ........... ........... ........... ...........
89331.............. Retrograde ejaculation NI................ A................. ........... ........... ........... ........... ...........
anal.
89335.............. Cryopreserve testicular CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
tiss.
89342.............. Storage/year; embryo(s)... CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89343.............. Storage/year; sperm/semen. CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89344.............. Storage/year; reprod CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
tissue.
89346.............. Storage/year; oocyte(s)... CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
89352.............. Thawing cryopresrved; CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
embryo.
[[Page 67095]]
89353.............. Thawing cryopresrved; CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
sperm.
89354.............. Thaw cryoprsvrd; reprod CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
tiss.
89356.............. Thawing cryopresrved; CH................ X................. 0344 0.8167 $52.02 $15.66 $10.40
oocyte.
90281.............. Human ig, im.............. .................. E................. ........... ........... ........... ........... ...........
90283.............. Human ig, iv.............. .................. E................. ........... ........... ........... ........... ...........
90284.............. Human ig, sc.............. NI................ E................. ........... ........... ........... ........... ...........
90287.............. Botulinum antitoxin....... .................. E................. ........... ........... ........... ........... ...........
90288.............. Botulism ig, iv........... .................. E................. ........... ........... ........... ........... ...........
90291.............. Cmv ig, iv................ .................. E................. ........... ........... ........... ........... ...........
90296.............. Diphtheria antitoxin...... .................. N................. ........... ........... ........... ........... ...........
90371.............. Hep b ig, im.............. .................. K................. 1630 ........... $122.02 ........... $24.40
90375.............. Rabies ig, im/sc.......... .................. K................. 9133 ........... $68.22 ........... $13.64
90376.............. Rabies ig, heat treated... .................. K................. 9134 ........... $71.69 ........... $14.34
90378.............. Rsv ig, im, 50mg.......... .................. E................. ........... ........... ........... ........... ...........
90379.............. Rsv ig, iv................ .................. E................. ........... ........... ........... ........... ...........
90384.............. Rh ig, full-dose, im...... .................. E................. ........... ........... ........... ........... ...........
90385.............. Rh ig, minidose, im....... .................. N................. ........... ........... ........... ........... ...........
90386.............. Rh ig, iv................. .................. E................. ........... ........... ........... ........... ...........
90389.............. Tetanus ig, im............ .................. E................. ........... ........... ........... ........... ...........
90393.............. Vaccina ig, im............ .................. N................. ........... ........... ........... ........... ...........
90396.............. Varicella-zoster ig, im... .................. K................. 9135 ........... $122.74 ........... $24.55
90399.............. Immune globulin........... .................. E................. ........... ........... ........... ........... ...........
90465.............. Immune admin 1 inj, < 8 .................. B................. ........... ........... ........... ........... ...........
yrs.
90466.............. Immune admin addl inj, < 8 .................. B................. ........... ........... ........... ........... ...........
y.
90467.............. Immune admin o or n, < 8 .................. B................. ........... ........... ........... ........... ...........
yrs.
90468.............. Immune admin o/n, addl < 8 .................. B................. ........... ........... ........... ........... ...........
y.
90471.............. Immunization admin........ .................. S................. 0437 0.3945 $25.13 ........... $5.03
90472.............. Immunization admin, each .................. S................. 0436 0.2545 $16.21 ........... $3.24
add.
90473.............. Immune admin oral/nasal... .................. S................. 0436 0.2545 $16.21 ........... $3.24
90474.............. Immune admin oral/nasal .................. S................. 0436 0.2545 $16.21 ........... $3.24
addl.
90476.............. Adenovirus vaccine, type 4 .................. N................. ........... ........... ........... ........... ...........
90477.............. Adenovirus vaccine, type 7 .................. N................. ........... ........... ........... ........... ...........
90581.............. Anthrax vaccine, sc....... .................. N................. ........... ........... ........... ........... ...........
90585.............. Bcg vaccine, percut....... .................. K................. 9137 ........... $118.98 ........... $23.80
90586.............. Bcg vaccine, intravesical. .................. B................. ........... ........... ........... ........... ...........
90632.............. Hep a vaccine, adult im... .................. N................. ........... ........... ........... ........... ...........
90633.............. Hep a vacc, ped/adol, 2 .................. N................. ........... ........... ........... ........... ...........
dose.
90634.............. Hep a vacc, ped/adol, 3 .................. N................. ........... ........... ........... ........... ...........
dose.
90636.............. Hep a/hep b vacc, adult im .................. N................. ........... ........... ........... ........... ...........
90645.............. Hib vaccine, hboc, im..... .................. N................. ........... ........... ........... ........... ...........
90646.............. Hib vaccine, prp-d, im.... .................. N................. ........... ........... ........... ........... ...........
90647.............. Hib vaccine, prp-omp, im.. .................. N................. ........... ........... ........... ........... ...........
90648.............. Hib vaccine, prp-t, im.... .................. N................. ........... ........... ........... ........... ...........
90649.............. H papilloma vacc 3 dose im .................. B................. ........... ........... ........... ........... ...........
90655.............. Flu vaccine no preserv 6- .................. L................. ........... ........... ........... ........... ...........
35m.
90656.............. Flu vaccine no preserv 3 & .................. L................. ........... ........... ........... ........... ...........
>.
90657.............. Flu vaccine, 3 yrs, im.... .................. L................. ........... ........... ........... ........... ...........
90658.............. Flu vaccine, 3 yrs & >, im .................. L................. ........... ........... ........... ........... ...........
90660.............. Flu vaccine, nasal........ .................. L................. ........... ........... ........... ........... ...........
90661.............. Flu vacc cell cult prsv NI................ L................. ........... ........... ........... ........... ...........
free.
90662.............. Flu vacc prsv free inc NI................ L................. ........... ........... ........... ........... ...........
antig.
90663.............. Flu vacc pandemic......... NI................ L................. ........... ........... ........... ........... ...........
90665.............. Lyme disease vaccine, im.. .................. N................. ........... ........... ........... ........... ...........
90669.............. Pneumococcal vacc, ped <5. CH................ L................. ........... ........... ........... ........... ...........
90675.............. Rabies vaccine, im........ .................. K................. 9139 ........... $150.80 ........... $30.16
90676.............. Rabies vaccine, id........ .................. K................. 9140 ........... $119.86 ........... $23.97
90680.............. Rotovirus vacc 3 dose, .................. N................. ........... ........... ........... ........... ...........
oral.
90690.............. Typhoid vaccine, oral..... .................. N................. ........... ........... ........... ........... ...........
90691.............. Typhoid vaccine, im....... .................. N................. ........... ........... ........... ........... ...........
90692.............. Typhoid vaccine, h-p, sc/ .................. N................. ........... ........... ........... ........... ...........
id.
90693.............. Typhoid vaccine, akd, sc.. .................. B................. ........... ........... ........... ........... ...........
90698.............. Dtap-hib-ip vaccine, im... .................. N................. ........... ........... ........... ........... ...........
90700.............. Dtap vaccine, < 7 yrs, im. .................. N................. ........... ........... ........... ........... ...........
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................. ........... ........... ........... ........... ...........
90708.............. Measles-rubella vaccine, .................. K................. 9141 ........... $45.53 ........... $9.11
sc.
90710.............. Mmrv vaccine, sc.......... .................. N................. ........... ........... ........... ........... ...........
90712.............. Oral poliovirus vaccine... .................. N................. ........... ........... ........... ........... ...........
90713.............. Poliovirus, ipv, sc/im.... .................. N................. ........... ........... ........... ........... ...........
90714.............. Td vaccine no prsrv >/= 7 .................. N................. ........... ........... ........... ........... ...........
im.
90715.............. Tdap vaccine >7 im........ .................. N................. ........... ........... ........... ........... ...........
90716.............. Chicken pox vaccine, sc... .................. B................. ........... ........... ........... ........... ...........
90717.............. Yellow fever vaccine, sc.. .................. N................. ........... ........... ........... ........... ...........
90718.............. Td vaccine > 7, im........ .................. N................. ........... ........... ........... ........... ...........
90719.............. Diphtheria vaccine, im.... .................. N................. ........... ........... ........... ........... ...........
[[Page 67096]]
90720.............. Dtp/hib vaccine, im....... CH................ N................. ........... ........... ........... ........... ...........
90721.............. Dtap/hib vaccine, im...... .................. N................. ........... ........... ........... ........... ...........
90723.............. Dtap-hep b-ipv vaccine, im .................. E................. ........... ........... ........... ........... ...........
90725.............. Cholera vaccine, .................. N................. ........... ........... ........... ........... ...........
injectable.
90727.............. Plague vaccine, im........ CH................ N................. ........... ........... ........... ........... ...........
90732.............. Pneumococcal vaccine...... .................. L................. ........... ........... ........... ........... ...........
90733.............. Meningococcal vaccine, sc. .................. K................. 9143 ........... $85.29 ........... $17.06
90734.............. Meningococcal vaccine, im. .................. K................. 9145 ........... $82.00 ........... $16.40
90735.............. Encephalitis vaccine, sc.. .................. K................. 9144 ........... $98.17 ........... $19.63
90736.............. Zoster vacc, sc........... .................. B................. ........... ........... ........... ........... ...........
90740.............. Hepb vacc, ill pat 3 dose .................. F................. ........... ........... ........... ........... ...........
im.
90743.............. Hep b vacc, adol, 2 dose, .................. F................. ........... ........... ........... ........... ...........
im.
90744.............. Hepb vacc ped/adol 3 dose .................. F................. ........... ........... ........... ........... ...........
im.
90746.............. Hep b vaccine, adult, im.. .................. F................. ........... ........... ........... ........... ...........
90747.............. Hepb vacc, ill pat 4 dose .................. F................. ........... ........... ........... ........... ...........
im.
90748.............. Hep b/hib vaccine, im..... .................. E................. ........... ........... ........... ........... ...........
90749.............. Vaccine toxoid............ .................. N................. ........... ........... ........... ........... ...........
90760.............. Hydration iv infusion, .................. S................. 0440 1.7998 $114.64 ........... $22.93
init.
90761.............. Hydrate iv infusion, add- .................. S................. 0437 0.3945 $25.13 ........... $5.03
on.
90765.............. Ther/proph/diag iv inf, .................. S................. 0440 1.7998 $114.64 ........... $22.93
init.
90766.............. Ther/proph/dg iv inf, add- .................. S................. 0437 0.3945 $25.13 ........... $5.03
on.
90767.............. Tx/proph/dg addl seq iv .................. S................. 0437 0.3945 $25.13 ........... $5.03
inf.
90768.............. Ther/diag concurrent inf.. .................. N................. ........... ........... ........... ........... ...........
90769.............. Sc ther infusion, up to 1 NI................ S................. 0440 1.7998 $114.64 ........... $22.93
hr.
90770.............. Sc ther infusion, addl hr. NI................ S................. 0437 0.3945 $25.13 ........... $5.03
90771.............. Sc ther infusion, reset NI................ S................. 0438 0.8041 $51.22 ........... $10.24
pump.
90772.............. Ther/proph/diag inj, sc/im .................. S................. 0437 0.3945 $25.13 ........... $5.03
90773.............. Ther/proph/diag inj, ia... .................. S................. 0438 0.8041 $51.22 ........... $10.24
90774.............. Ther/proph/diag inj, iv .................. S................. 0438 0.8041 $51.22 ........... $10.24
push.
90775.............. Tx/pro/dx inj new drug .................. S................. 0438 0.8041 $51.22 ........... $10.24
addon.
90776.............. Tx/pro/dx inj same drug NI................ N................. ........... ........... ........... ........... ...........
adon.
90779.............. Ther/prop/diag inj/inf .................. S................. 0436 0.2545 $16.21 ........... $3.24
proc.
90801.............. Psy dx interview.......... CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
90802.............. Intac psy dx interview.... CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
90804.............. Psytx, office, 20-30 min.. CH................ Q................. 0322 1.1729 $74.71 ........... $14.94
90805.............. Psytx, off, 20-30 min w/ CH................ Q................. 0322 1.1729 $74.71 ........... $14.94
e&m.
90806.............. Psytx, off, 45-50 min..... CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
90807.............. Psytx, off, 45-50 min w/ CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
e&m.
90808.............. Psytx, office, 75-80 min.. CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
90809.............. Psytx, off, 75-80, w/e&m.. CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
90810.............. Intac psytx, off, 20-30 CH................ Q................. 0322 1.1729 $74.71 ........... $14.94
min.
90811.............. Intac psytx, 20-30, w/e&m. CH................ Q................. 0322 1.1729 $74.71 ........... $14.94
90812.............. Intac psytx, off, 45-50 CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
min.
90813.............. Intac psytx, 45-50 min w/ CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
e&m.
90814.............. Intac psytx, off, 75-80 CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
min.
90815.............. Intac psytx, 75-80 w/e&m.. CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
90816.............. Psytx, hosp, 20-30 min.... CH................ Q................. 0322 1.1729 $74.71 ........... $14.94
90817.............. Psytx, hosp, 20-30 min w/ CH................ Q................. 0322 1.1729 $74.71 ........... $14.94
e&m.
90818.............. Psytx, hosp, 45-50 min.... CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
90819.............. Psytx, hosp, 45-50 min w/ CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
e&m.
90821.............. Psytx, hosp, 75-80 min.... CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
90822.............. Psytx, hosp, 75-80 min w/ CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
e&m.
90823.............. Intac psytx, hosp, 20-30 CH................ Q................. 0322 1.1729 $74.71 ........... $14.94
min.
90824.............. Intac psytx, hsp 20-30 w/ CH................ Q................. 0322 1.1729 $74.71 ........... $14.94
e&m.
90826.............. Intac psytx, hosp, 45-50 CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
min.
90827.............. Intac psytx, hsp 45-50 w/ CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
e&m.
90828.............. Intac psytx, hosp, 75-80 CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
min.
90829.............. Intac psytx, hsp 75-80 w/ CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
e&m.
90845.............. Psychoanalysis............ CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
90846.............. Family psytx w/o patient.. CH................ Q................. 0324 2.3616 $150.42 ........... $30.08
90847.............. Family psytx w/patient.... CH................ Q................. 0324 2.3616 $150.42 ........... $30.08
90849.............. Multiple family group CH................ Q................. 0325 0.9913 $63.14 $13.81 $12.63
psytx.
90853.............. Group psychotherapy....... CH................ Q................. 0325 0.9913 $63.14 $13.81 $12.63
90857.............. Intac group psytx......... CH................ Q................. 0325 0.9913 $63.14 $13.81 $12.63
90862.............. Medication management..... CH................ Q................. 0606 1.3226 $84.24 ........... $16.85
90865.............. Narcosynthesis............ CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
90870.............. Electroconvulsive therapy. .................. S................. 0320 5.7299 $364.96 $80.06 $72.99
90875.............. Psychophysiological .................. E................. ........... ........... ........... ........... ...........
therapy.
90876.............. Psychophysiological .................. E................. ........... ........... ........... ........... ...........
therapy.
90880.............. Hypnotherapy.............. CH................ Q................. 0323 1.6044 $102.19 ........... $20.44
90882.............. Environmental manipulation .................. E................. ........... ........... ........... ........... ...........
90885.............. Psy evaluation of records. .................. N................. ........... ........... ........... ........... ...........
90887.............. Consultation with family.. .................. N................. ........... ........... ........... ........... ...........
90889.............. Preparation of report..... .................. N................. ........... ........... ........... ........... ...........
90899.............. Psychiatric service/ CH................ Q................. 0322 1.1729 $74.71 ........... $14.94
therapy.
90901.............. Biofeedback train, any .................. A................. ........... ........... ........... ........... ...........
meth.
90911.............. Biofeedback peri/uro/ CH................ T................. 0126 1.0356 $65.96 $16.21 $13.19
rectal.
90918.............. ESRD related services, .................. E................. ........... ........... ........... ........... ...........
month.
90919.............. ESRD related services, .................. E................. ........... ........... ........... ........... ...........
month.
90920.............. ESRD related services, .................. E................. ........... ........... ........... ........... ...........
month.
[[Page 67097]]
90921.............. ESRD related services, .................. E................. ........... ........... ........... ........... ...........
month.
90922.............. ESRD related services, day .................. E................. ........... ........... ........... ........... ...........
90923.............. Esrd related services, day .................. E................. ........... ........... ........... ........... ...........
90924.............. Esrd related services, day .................. E................. ........... ........... ........... ........... ...........
90925.............. Esrd related services, day .................. E................. ........... ........... ........... ........... ...........
90935.............. Hemodialysis, one .................. S................. 0170 6.5383 $416.45 ........... $83.29
evaluation.
90937.............. Hemodialysis, repeated .................. B................. ........... ........... ........... ........... ...........
eval.
90940.............. Hemodialysis access study. .................. N................. ........... ........... ........... ........... ...........
90945.............. Dialysis, one evaluation.. .................. S................. 0170 6.5383 $416.45 ........... $83.29
90947.............. Dialysis, repeated eval... .................. B................. ........... ........... ........... ........... ...........
90989.............. Dialysis training, .................. B................. ........... ........... ........... ........... ...........
complete.
90993.............. Dialysis training, incompl .................. B................. ........... ........... ........... ........... ...........
90997.............. Hemoperfusion............. .................. B................. ........... ........... ........... ........... ...........
90999.............. Dialysis procedure........ .................. B................. ........... ........... ........... ........... ...........
91000.............. Esophageal intubation..... .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
91010.............. Esophagus motility study.. .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
91011.............. Esophagus motility study.. .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
91012.............. Esophagus motility study.. .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
91020.............. Gastric motility studies.. .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
91022.............. Duodenal motility study... .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
91030.............. Acid perfusion of .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
esophagus.
91034.............. Gastroesophageal reflux .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
test.
91035.............. G-esoph reflx tst w/ .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
electrod.
91037.............. Esoph imped function test. .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
91038.............. Esoph imped funct test > .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
1h.
91040.............. Esoph balloon distension .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
tst.
91052.............. Gastric analysis test..... .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
91055.............. Gastric intubation for .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
smear.
91065.............. Breath hydrogen test...... .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
91100.............. Pass intestine bleeding .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
tube.
91105.............. Gastric intubation .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
treatment.
91110.............. Gi tract capsule endoscopy .................. T................. 0142 9.5292 $606.95 $152.78 $121.39
91111.............. Esophageal capsule .................. T................. 0141 8.5030 $541.59 $143.38 $108.32
endoscopy.
91120.............. Rectal sensation test..... .................. T................. 0126 1.0356 $65.96 $16.21 $13.19
91122.............. Anal pressure record...... .................. T................. 0164 2.0077 $127.88 ........... $25.58
91123.............. Irrigate fecal impaction.. .................. N................. ........... ........... ........... ........... ...........
91132.............. Electrogastrography....... .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
91133.............. Electrogastrography w/test .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
91299.............. Gastroenterology procedure .................. X................. 0360 1.5330 $97.64 $33.88 $19.53
92002.............. Eye exam, new patient..... .................. V................. 0605 0.9964 $63.46 ........... $12.69
92004.............. Eye exam, new patient..... .................. V................. 0606 1.3226 $84.24 ........... $16.85
92012.............. Eye exam established pat.. .................. V................. 0604 0.8388 $53.43 ........... $10.69
92014.............. Eye exam & treatment...... .................. V................. 0605 0.9964 $63.46 ........... $12.69
92015.............. Refraction................ .................. E................. ........... ........... ........... ........... ...........
92018.............. New eye exam & treatment.. .................. T................. 0699 13.7453 $875.49 ........... $175.10
92019.............. Eye exam & treatment...... .................. T................. 0699 13.7453 $875.49 ........... $175.10
92020.............. Special eye evaluation.... .................. S................. 0230 0.5903 $37.60 ........... $7.52
92025.............. Corneal topography........ .................. S................. 0698 0.8696 $55.39 ........... $11.08
92060.............. Special eye evaluation.... CH................ S................. 0698 0.8696 $55.39 ........... $11.08
92065.............. Orthoptic/pleoptic CH................ S................. 0698 0.8696 $55.39 ........... $11.08
training.
92070.............. Fitting of contact lens... .................. N................. ........... ........... ........... ........... ...........
92081.............. Visual field .................. S................. 0230 0.5903 $37.60 ........... $7.52
examination(s).
92082.............. Visual field CH................ S................. 0698 0.8696 $55.39 ........... $11.08
examination(s).
92083.............. Visual field CH................ S................. 0698 0.8696 $55.39 ........... $11.08
examination(s).
92100.............. Serial tonometry exam(s).. .................. N................. ........... ........... ........... ........... ...........
92120.............. Tonography & eye CH................ S................. 0698 0.8696 $55.39 ........... $11.08
evaluation.
92130.............. Water provocation .................. S................. 0230 0.5903 $37.60 ........... $7.52
tonography.
92135.............. Ophth dx imaging post seg. .................. S................. 0230 0.5903 $37.60 ........... $7.52
92136.............. Ophthalmic biometry....... .................. S................. 0698 0.8696 $55.39 ........... $11.08
92140.............. Glaucoma provocative tests .................. S................. 0230 0.5903 $37.60 ........... $7.52
92225.............. Special eye exam, initial. .................. S................. 0230 0.5903 $37.60 ........... $7.52
92226.............. Special eye exam, CH................ S................. 0698 0.8696 $55.39 ........... $11.08
subsequent.
92230.............. Eye exam with photos...... .................. S................. 0231 2.1790 $138.79 ........... $27.76
92235.............. Eye exam with photos...... .................. S................. 0231 2.1790 $138.79 ........... $27.76
92240.............. Icg angiography........... .................. S................. 0231 2.1790 $138.79 ........... $27.76
92250.............. Eye exam with photos...... CH................ S................. 0698 0.8696 $55.39 ........... $11.08
92260.............. Ophthalmoscopy/dynamometry .................. S................. 0230 0.5903 $37.60 ........... $7.52
92265.............. Eye muscle evaluation..... CH................ S................. 0698 0.8696 $55.39 ........... $11.08
92270.............. Electro-oculography....... .................. S................. 0230 0.5903 $37.60 ........... $7.52
92275.............. Electroretinography....... .................. S................. 0231 2.1790 $138.79 ........... $27.76
92283.............. Color vision examination.. .................. S................. 0230 0.5903 $37.60 ........... $7.52
92284.............. Dark adaptation eye exam.. .................. S................. 0698 0.8696 $55.39 ........... $11.08
92285.............. Eye photography........... CH................ S................. 0698 0.8696 $55.39 ........... $11.08
92286.............. Internal eye photography.. CH................ S................. 0231 2.1790 $138.79 ........... $27.76
92287.............. Internal eye photography.. CH................ S................. 0231 2.1790 $138.79 ........... $27.76
92310.............. Contact lens fitting...... .................. E................. ........... ........... ........... ........... ...........
92311.............. Contact lens fitting...... CH................ S................. 0698 0.8696 $55.39 ........... $11.08
92312.............. Contact lens fitting...... CH................ S................. 0698 0.8696 $55.39 ........... $11.08
92313.............. Contact lens fitting...... CH................ S................. 0230 0.5903 $37.60 ........... $7.52
92314.............. Prescription of contact .................. E................. ........... ........... ........... ........... ...........
lens.
[[Page 67098]]
92315.............. Prescription of contact CH................ S................. 0230 0.5903 $37.60 ........... $7.52
lens.
92316.............. Prescription of contact CH................ S................. 0698 0.8696 $55.39 ........... $11.08
lens.
92317.............. Prescription of contact CH................ S................. 0230 0.5903 $37.60 ........... $7.52
lens.
92325.............. Modification of contact CH................ S................. 0230 0.5903 $37.60 ........... $7.52
lens.
92326.............. Replacement of contact CH................ S................. 0698 0.8696 $55.39 ........... $11.08
lens.
92340.............. Fitting of spectacles..... .................. E................. ........... ........... ........... ........... ...........
92341.............. Fitting of spectacles..... .................. E................. ........... ........... ........... ........... ...........
92342.............. Fitting of spectacles..... .................. E................. ........... ........... ........... ........... ...........
92352.............. Special spectacles fitting CH................ S................. 0698 0.8696 $55.39 ........... $11.08
92353.............. Special spectacles fitting CH................ S................. 0230 0.5903 $37.60 ........... $7.52
92354.............. Special spectacles fitting CH................ S................. 0230 0.5903 $37.60 ........... $7.52
92355.............. Special spectacles fitting CH................ S................. 0230 0.5903 $37.60 ........... $7.52
92358.............. Eye prosthesis service.... CH................ S................. 0230 0.5903 $37.60 ........... $7.52
92370.............. Repair & adjust spectacles .................. E................. ........... ........... ........... ........... ...........
92371.............. Repair & adjust spectacles CH................ S................. 0230 0.5903 $37.60 ........... $7.52
92499.............. Eye service or procedure.. .................. S................. 0230 0.5903 $37.60 ........... $7.52
92502.............. Ear and throat examination .................. T................. 0251 2.5002 $159.25 ........... $31.85
92504.............. Ear microscopy examination .................. N................. ........... ........... ........... ........... ...........
92506.............. Speech/hearing evaluation. .................. A................. ........... ........... ........... ........... ...........
92507.............. Speech/hearing therapy.... .................. A................. ........... ........... ........... ........... ...........
92508.............. Speech/hearing therapy.... .................. A................. ........... ........... ........... ........... ...........
92511.............. Nasopharyngoscopy......... .................. T................. 0071 0.8224 $52.38 $11.20 $10.48
92512.............. Nasal function studies.... .................. X................. 0363 0.8067 $51.38 $17.10 $10.28
92516.............. Facial nerve function test .................. X................. 0660 1.4312 $91.16 $28.06 $18.23
92520.............. Laryngeal function studies .................. X................. 0660 1.4312 $91.16 $28.06 $18.23
92526.............. Oral function therapy..... .................. A................. ........... ........... ........... ........... ...........
92531.............. Spontaneous nystagmus .................. N................. ........... ........... ........... ........... ...........
study.
92532.............. Positional nystagmus test. .................. N................. ........... ........... ........... ........... ...........
92533.............. Caloric vestibular test... .................. N................. ........... ........... ........... ........... ...........
92534.............. Optokinetic nystagmus test .................. N................. ........... ........... ........... ........... ...........
92541.............. Spontaneous nystagmus test .................. X................. 0363 0.8067 $51.38 $17.10 $10.28
92542.............. Positional nystagmus test. .................. X................. 0363 0.8067 $51.38 $17.10 $10.28
92543.............. Caloric vestibular test... .................. X................. 0660 1.4312 $91.16 $28.06 $18.23
92544.............. Optokinetic nystagmus test .................. X................. 0363 0.8067 $51.38 $17.10 $10.28
92545.............. Oscillating tracking test. .................. X................. 0363 0.8067 $51.38 $17.10 $10.28
92546.............. Sinusoidal rotational test .................. X................. 0660 1.4312 $91.16 $28.06 $18.23
92547.............. Supplemental electrical CH................ N................. ........... ........... ........... ........... ...........
test.
92548.............. Posturography............. .................. X................. 0660 1.4312 $91.16 $28.06 $18.23
92551.............. Pure tone hearing test, .................. E................. ........... ........... ........... ........... ...........
air.
92552.............. Pure tone audiometry, air. .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92553.............. Audiometry, air & bone.... .................. X................. 0365 1.2549 $79.93 $18.52 $15.99
92555.............. Speech threshold .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
audiometry.
92556.............. Speech audiometry, .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
complete.
92557.............. Comprehensive hearing test .................. X................. 0365 1.2549 $79.93 $18.52 $15.99
92559.............. Group audiometric testing. .................. E................. ........... ........... ........... ........... ...........
92560.............. Bekesy audiometry, screen. .................. E................. ........... ........... ........... ........... ...........
92561.............. Bekesy audiometry, .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
diagnosis.
92562.............. Loudness balance test..... .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92563.............. Tone decay hearing test... .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92564.............. Sisi hearing test......... .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92565.............. Stenger test, pure tone... .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92567.............. Tympanometry.............. .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92568.............. Acoustic refl threshold .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
tst.
92569.............. Acoustic reflex decay test .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92571.............. Filtered speech hearing .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
test.
92572.............. Staggered spondaic word .................. X................. 0366 1.7624 $112.25 $25.79 $22.45
test.
92575.............. Sensorineural acuity test. .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92576.............. Synthetic sentence test... .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92577.............. Stenger test, speech...... .................. X................. 0366 1.7624 $112.25 $25.79 $22.45
92579.............. Visual audiometry (vra)... .................. X................. 0365 1.2549 $79.93 $18.52 $15.99
92582.............. Conditioning play .................. X................. 0365 1.2549 $79.93 $18.52 $15.99
audiometry.
92583.............. Select picture audiometry. .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92584.............. Electrocochleography...... CH................ S................. 0216 2.6846 $170.99 ........... $34.20
92585.............. Auditor evoke potent, .................. S................. 0216 2.6846 $170.99 ........... $34.20
compre.
92586.............. Auditor evoke potent, .................. S................. 0218 1.1550 $73.57 ........... $14.71
limit.
92587.............. Evoked auditory test...... .................. X................. 0363 0.8067 $51.38 $17.10 $10.28
92588.............. Evoked auditory test...... .................. X................. 0660 1.4312 $91.16 $28.06 $18.23
92590.............. Hearing aid exam, one ear. .................. E................. ........... ........... ........... ........... ...........
92591.............. Hearing aid exam, both .................. E................. ........... ........... ........... ........... ...........
ears.
92592.............. Hearing aid check, one ear .................. E................. ........... ........... ........... ........... ...........
92593.............. Hearing aid check, both .................. E................. ........... ........... ........... ........... ...........
ears.
92594.............. Electro hearng aid test, .................. E................. ........... ........... ........... ........... ...........
one.
92595.............. Electro hearng aid tst, .................. E................. ........... ........... ........... ........... ...........
both.
92596.............. Ear protector evaluation.. .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92597.............. Oral speech device eval... .................. A................. ........... ........... ........... ........... ...........
92601.............. Cochlear implt f/up exam < .................. X................. 0366 1.7624 $112.25 $25.79 $22.45
7.
92602.............. Reprogram cochlear implt < .................. X................. 0366 1.7624 $112.25 $25.79 $22.45
7.
92603.............. Cochlear implt f/up exam 7 .................. X................. 0366 1.7624 $112.25 $25.79 $22.45
>.
92604.............. Reprogram cochlear implt 7 .................. X................. 0366 1.7624 $112.25 $25.79 $22.45
>.
92605.............. Eval for nonspeech device .................. A................. ........... ........... ........... ........... ...........
rx.
[[Page 67099]]
92606.............. Non-speech device service. .................. A................. ........... ........... ........... ........... ...........
92607.............. Ex for speech device rx, .................. A................. ........... ........... ........... ........... ...........
1hr.
92608.............. Ex for speech device rx .................. A................. ........... ........... ........... ........... ...........
addl.
92609.............. Use of speech device .................. A................. ........... ........... ........... ........... ...........
service.
92610.............. Evaluate swallowing .................. A................. ........... ........... ........... ........... ...........
function.
92611.............. Motion fluoroscopy/swallow .................. A................. ........... ........... ........... ........... ...........
92612.............. Endoscopy swallow tst .................. A................. ........... ........... ........... ........... ...........
(fees).
92613.............. Endoscopy swallow tst .................. B................. ........... ........... ........... ........... ...........
(fees).
92614.............. Laryngoscopic sensory test .................. A................. ........... ........... ........... ........... ...........
92615.............. Eval laryngoscopy sense .................. E................. ........... ........... ........... ........... ...........
tst.
92616.............. Fees w/laryngeal sense .................. A................. ........... ........... ........... ........... ...........
test.
92617.............. Interprt fees/laryngeal .................. E................. ........... ........... ........... ........... ...........
test.
92620.............. Auditory function, 60 min. .................. X................. 0365 1.2549 $79.93 $18.52 $15.99
92621.............. Auditory function, + 15 .................. N................. ........... ........... ........... ........... ...........
min.
92625.............. Tinnitus assessment....... .................. X................. 0365 1.2549 $79.93 $18.52 $15.99
92626.............. Eval aud rehab status..... .................. X................. 0365 1.2549 $79.93 $18.52 $15.99
92627.............. Eval aud status rehab add- .................. N................. ........... ........... ........... ........... ...........
on.
92630.............. Aud rehab pre-ling hear .................. E................. ........... ........... ........... ........... ...........
loss.
92633.............. Aud rehab postling hear .................. E................. ........... ........... ........... ........... ...........
loss.
92640.............. Aud brainstem implt .................. X................. 0365 1.2549 $79.93 $18.52 $15.99
programg.
92700.............. Ent procedure/service..... .................. X................. 0364 0.4490 $28.60 $7.06 $5.72
92950.............. Heart/lung resuscitation .................. S................. 0094 2.4590 $156.62 $46.29 $31.32
cpr.
92953.............. Temporary external pacing. .................. S................. 0094 2.4590 $156.62 $46.29 $31.32
92960.............. Cardioversion electric, .................. S................. 0679 5.4502 $347.15 $95.30 $69.43
ext.
92961.............. Cardioversion, electric, .................. S................. 0679 5.4502 $347.15 $95.30 $69.43
int.
92970.............. Cardioassist, internal.... .................. C................. ........... ........... ........... ........... ...........
92971.............. Cardioassist, external.... .................. C................. ........... ........... ........... ........... ...........
92973.............. Percut coronary .................. T................. 0088 38.7673 $2,469.24 $655.22 $493.85
thrombectomy.
92974.............. Cath place, cardio .................. T................. 0103 14.6576 $933.60 ........... $186.72
brachytx.
92975.............. Dissolve clot, heart .................. C................. ........... ........... ........... ........... ...........
vessel.
92977.............. Dissolve clot, heart .................. T................. 0676 2.4824 $158.11 ........... $31.62
vessel.
92978.............. Intravasc us, heart add-on CH................ N................. ........... ........... ........... ........... ...........
92979.............. Intravasc us, heart add-on CH................ N................. ........... ........... ........... ........... ...........
92980.............. Insert intracoronary stent .................. T................. 0104 89.0159 $5,669.78 ........... $1,133.96
92981.............. Insert intracoronary stent .................. T................. 0104 89.0159 $5,669.78 ........... $1,133.96
92982.............. Coronary artery dilation.. .................. T................. 0083 45.3845 $2,890.72 ........... $578.14
92984.............. Coronary artery dilation.. .................. T................. 0083 45.3845 $2,890.72 ........... $578.14
92986.............. Revision of aortic valve.. .................. T................. 0083 45.3845 $2,890.72 ........... $578.14
92987.............. Revision of mitral valve.. .................. T................. 0083 45.3845 $2,890.72 ........... $578.14
92990.............. Revision of pulmonary .................. T................. 0083 45.3845 $2,890.72 ........... $578.14
valve.
92992.............. Revision of heart chamber. .................. C................. ........... ........... ........... ........... ...........
92993.............. Revision of heart chamber. .................. C................. ........... ........... ........... ........... ...........
92995.............. Coronary atherectomy...... .................. T................. 0082 87.5137 $5,574.10 ........... $1,114.82
92996.............. Coronary atherectomy add- .................. T................. 0082 87.5137 $5,574.10 ........... $1,114.82
on.
92997.............. Pul art balloon repr, CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
percut.
92998.............. Pul art balloon repr, CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
percut.
93000.............. Electrocardiogram, .................. B................. ........... ........... ........... ........... ...........
complete.
93005.............. Electrocardiogram, tracing .................. S................. 0099 0.3892 $24.79 ........... $4.96
93010.............. Electrocardiogram report.. .................. B................. ........... ........... ........... ........... ...........
93012.............. Transmission of ecg....... .................. N................. ........... ........... ........... ........... ...........
93014.............. Report on transmitted ecg. .................. B................. ........... ........... ........... ........... ...........
93015.............. Cardiovascular stress test .................. B................. ........... ........... ........... ........... ...........
93016.............. Cardiovascular stress test .................. B................. ........... ........... ........... ........... ...........
93017.............. Cardiovascular stress test .................. X................. 0100 2.5547 $162.72 $41.44 $32.54
93018.............. Cardiovascular stress test .................. B................. ........... ........... ........... ........... ...........
93024.............. Cardiac drug stress test.. .................. X................. 0100 2.5547 $162.72 $41.44 $32.54
93025.............. Microvolt t-wave assess... .................. X................. 0100 2.5547 $162.72 $41.44 $32.54
93040.............. Rhythm ECG with report.... .................. B................. ........... ........... ........... ........... ...........
93041.............. Rhythm ECG, tracing....... .................. S................. 0099 0.3892 $24.79 ........... $4.96
93042.............. Rhythm ECG, report........ .................. B................. ........... ........... ........... ........... ...........
93224.............. ECG monitor/report, 24 hrs .................. B................. ........... ........... ........... ........... ...........
93225.............. ECG monitor/record, 24 hrs .................. X................. 0097 1.0015 $63.79 $23.79 $12.76
93226.............. ECG monitor/report, 24 hrs .................. X................. 0097 1.0015 $63.79 $23.79 $12.76
93227.............. ECG monitor/review, 24 hrs .................. B................. ........... ........... ........... ........... ...........
93230.............. ECG monitor/report, 24 hrs .................. B................. ........... ........... ........... ........... ...........
93231.............. Ecg monitor/record, 24 hrs .................. X................. 0097 1.0015 $63.79 $23.79 $12.76
93232.............. ECG monitor/report, 24 hrs .................. X................. 0097 1.0015 $63.79 $23.79 $12.76
93233.............. ECG monitor/review, 24 hrs .................. B................. ........... ........... ........... ........... ...........
93235.............. ECG monitor/report, 24 hrs .................. B................. ........... ........... ........... ........... ...........
93236.............. ECG monitor/report, 24 hrs .................. X................. 0097 1.0015 $63.79 $23.79 $12.76
93237.............. ECG monitor/review, 24 hrs .................. B................. ........... ........... ........... ........... ...........
93268.............. ECG record/review......... .................. B................. ........... ........... ........... ........... ...........
93270.............. ECG recording............. .................. X................. 0097 1.0015 $63.79 $23.79 $12.76
93271.............. Ecg/monitoring and CH................ S................. 0663 1.5313 $97.53 ........... $19.51
analysis.
93272.............. Ecg/review, interpret only .................. B................. ........... ........... ........... ........... ...........
93278.............. ECG/signal-averaged....... CH................ X................. 0340 0.6310 $40.19 ........... $8.04
93303.............. Echo transthoracic........ .................. S................. 0269 6.3751 $406.06 ........... $81.21
93304.............. Echo transthoracic........ .................. S................. 0697 3.3401 $212.74 ........... $42.55
93307.............. Echo exam of heart........ .................. S................. 0269 6.3751 $406.06 ........... $81.21
93308.............. Echo exam of heart........ .................. S................. 0697 3.3401 $212.74 ........... $42.55
[[Page 67100]]
93312.............. Echo transesophageal...... .................. S................. 0270 8.2165 $523.34 $141.32 $104.67
93313.............. Echo transesophageal...... .................. S................. 0270 8.2165 $523.34 $141.32 $104.67
93314.............. Echo transesophageal...... .................. N................. ........... ........... ........... ........... ...........
93315.............. Echo transesophageal...... .................. S................. 0270 8.2165 $523.34 $141.32 $104.67
93316.............. Echo transesophageal...... .................. S................. 0270 8.2165 $523.34 $141.32 $104.67
93317.............. Echo transesophageal...... .................. N................. ........... ........... ........... ........... ...........
93318.............. Echo transesophageal .................. S................. 0270 8.2165 $523.34 $141.32 $104.67
intraop.
93320.............. Doppler echo exam, heart.. CH................ N................. ........... ........... ........... ........... ...........
93321.............. Doppler echo exam, heart.. CH................ N................. ........... ........... ........... ........... ...........
93325.............. Doppler color flow add-on. CH................ N................. ........... ........... ........... ........... ...........
93350.............. Echo transthoracic........ .................. S................. 0269 6.3751 $406.06 ........... $81.21
93501.............. Right heart .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
catheterization.
93503.............. Insert/place heart .................. T................. 0103 14.6576 $933.60 ........... $186.72
catheter.
93505.............. Biopsy of heart lining.... .................. T................. 0103 14.6576 $933.60 ........... $186.72
93508.............. Cath placement, .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
angiography.
93510.............. Left heart catheterization .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
93511.............. Left heart catheterization .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
93514.............. Left heart catheterization .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
93524.............. Left heart catheterization .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
93526.............. Rt & Lt heart catheters... .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
93527.............. Rt & Lt heart catheters... .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
93528.............. Rt & Lt heart catheters... .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
93529.............. Rt, lt heart .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
catheterization.
93530.............. Rt heart cath, congenital. .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
93531.............. R & l heart cath, .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
congenital.
93532.............. R & l heart cath, .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
congenital.
93533.............. R & l heart cath, .................. T................. 0080 38.9204 $2,479.00 $838.92 $495.80
congenital.
93539.............. Injection, cardiac cath... .................. N................. ........... ........... ........... ........... ...........
93540.............. Injection, cardiac cath... .................. N................. ........... ........... ........... ........... ...........
93541.............. Injection for lung .................. N................. ........... ........... ........... ........... ...........
angiogram.
93542.............. Injection for heart x-rays .................. N................. ........... ........... ........... ........... ...........
93543.............. Injection for heart x-rays .................. N................. ........... ........... ........... ........... ...........
93544.............. Injection for aortography. .................. N................. ........... ........... ........... ........... ...........
93545.............. Inject for coronary x-rays .................. N................. ........... ........... ........... ........... ...........
93555.............. Imaging, cardiac cath..... .................. N................. ........... ........... ........... ........... ...........
93556.............. Imaging, cardiac cath..... .................. N................. ........... ........... ........... ........... ...........
93561.............. Cardiac output measurement .................. N................. ........... ........... ........... ........... ...........
93562.............. Cardiac output measurement .................. N................. ........... ........... ........... ........... ...........
93571.............. Heart flow reserve measure CH................ N................. ........... ........... ........... ........... ...........
93572.............. Heart flow reserve measure CH................ N................. ........... ........... ........... ........... ...........
93580.............. Transcath closure of asd.. .................. T................. 0434 132.4129 $8,433.91 ........... $1,686.78
93581.............. Transcath closure of vsd.. .................. T................. 0434 132.4129 $8,433.91 ........... $1,686.78
93600.............. Bundle of His recording... CH................ S................. 0084 9.5834 $610.41 ........... $122.08
93602.............. Intra-atrial recording.... CH................ S................. 0084 9.5834 $610.41 ........... $122.08
93603.............. Right ventricular CH................ S................. 0084 9.5834 $610.41 ........... $122.08
recording.
93609.............. Map tachycardia, add-on... CH................ N................. ........... ........... ........... ........... ...........
93610.............. Intra-atrial pacing....... CH................ S................. 0084 9.5834 $610.41 ........... $122.08
93612.............. Intraventricular pacing... CH................ S................. 0084 9.5834 $610.41 ........... $122.08
93613.............. Electrophys map 3d, add-on CH................ N................. ........... ........... ........... ........... ...........
93615.............. Esophageal recording...... CH................ S................. 0084 9.5834 $610.41 ........... $122.08
93616.............. Esophageal recording...... CH................ S................. 0084 9.5834 $610.41 ........... $122.08
93618.............. Heart rhythm pacing....... CH................ S................. 0084 9.5834 $610.41 ........... $122.08
93619.............. Electrophysiology CH................ Q................. 0085 47.2949 $3,012.40 ........... $602.48
evaluation.
93620.............. Electrophysiology CH................ Q................. 0085 47.2949 $3,012.40 ........... $602.48
evaluation.
93621.............. Electrophysiology CH................ N................. ........... ........... ........... ........... ...........
evaluation.
93622.............. Electrophysiology CH................ N................. ........... ........... ........... ........... ...........
evaluation.
93623.............. Stimulation, pacing heart. CH................ N................. ........... ........... ........... ........... ...........
93624.............. Electrophysiologic study.. .................. T................. 0085 47.2949 $3,012.40 ........... $602.48
93631.............. Heart pacing, mapping..... CH................ N................. ........... ........... ........... ........... ...........
93640.............. Evaluation heart device... .................. N................. ........... ........... ........... ........... ...........
93641.............. Electrophysiology .................. N................. ........... ........... ........... ........... ...........
evaluation.
93642.............. Electrophysiology .................. S................. 0084 9.5834 $610.41 ........... $122.08
evaluation.
93650.............. Ablate heart dysrhythm CH................ Q................. 0085 47.2949 $3,012.40 ........... $602.48
focus.
93651.............. Ablate heart dysrhythm CH................ Q................. 0086 92.8564 $5,914.40 ........... $1,182.88
focus.
93652.............. Ablate heart dysrhythm CH................ Q................. 0086 92.8564 $5,914.40 ........... $1,182.88
focus.
93660.............. Tilt table evaluation..... .................. S................. 0101 4.1973 $267.34 $100.24 $53.47
93662.............. Intracardiac ecg (ice).... CH................ N................. ........... ........... ........... ........... ...........
93668.............. Peripheral vascular rehab. .................. E................. ........... ........... ........... ........... ...........
93701.............. Bioimpedance, thoracic.... .................. S................. 0099 0.3892 $24.79 ........... $4.96
93720.............. Total body plethysmography .................. B................. ........... ........... ........... ........... ...........
93721.............. Plethysmography tracing... .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
93722.............. Plethysmography report.... .................. B................. ........... ........... ........... ........... ...........
93724.............. Analyze pacemaker system.. .................. S................. 0690 0.3504 $22.32 $8.67 $4.46
93727.............. Analyze ilr system........ .................. S................. 0690 0.3504 $22.32 $8.67 $4.46
93731.............. Analyze pacemaker system.. .................. S................. 0690 0.3504 $22.32 $8.67 $4.46
93732.............. Analyze pacemaker system.. .................. S................. 0690 0.3504 $22.32 $8.67 $4.46
93733.............. Telephone analy, pacemaker .................. S................. 0690 0.3504 $22.32 $8.67 $4.46
93734.............. Analyze pacemaker system.. .................. S................. 0690 0.3504 $22.32 $8.67 $4.46
93735.............. Analyze pacemaker system.. .................. S................. 0690 0.3504 $22.32 $8.67 $4.46
93736.............. Telephonic analy, .................. S................. 0690 0.3504 $22.32 $8.67 $4.46
pacemaker.
[[Page 67101]]
93740.............. Temperature gradient .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
studies.
93741.............. Analyze ht pace device .................. S................. 0689 0.5946 $37.87 ........... $7.57
sngl.
93742.............. Analyze ht pace device .................. S................. 0689 0.5946 $37.87 ........... $7.57
sngl.
93743.............. Analyze ht pace device .................. S................. 0689 0.5946 $37.87 ........... $7.57
dual.
93744.............. Analyze ht pace device .................. S................. 0689 0.5946 $37.87 ........... $7.57
dual.
93745.............. Set-up cardiovert- .................. S................. 0689 0.5946 $37.87 ........... $7.57
defibrill.
93760.............. Cephalic thermogram....... .................. E................. ........... ........... ........... ........... ...........
93762.............. Peripheral thermogram..... .................. E................. ........... ........... ........... ........... ...........
93770.............. Measure venous pressure... .................. N................. ........... ........... ........... ........... ...........
93784.............. Ambulatory BP monitoring.. .................. E................. ........... ........... ........... ........... ...........
93786.............. Ambulatory BP recording... .................. X................. 0097 1.0015 $63.79 $23.79 $12.76
93788.............. Ambulatory BP analysis.... .................. X................. 0097 1.0015 $63.79 $23.79 $12.76
93790.............. Review/report BP recording .................. B................. ........... ........... ........... ........... ...........
93797.............. Cardiac rehab............. .................. S................. 0095 0.5685 $36.21 $13.86 $7.24
93798.............. Cardiac rehab/monitor..... .................. S................. 0095 0.5685 $36.21 $13.86 $7.24
93799.............. Cardiovascular procedure.. .................. X................. 0097 1.0015 $63.79 $23.79 $12.76
93875.............. Extracranial study........ .................. S................. 0096 1.4689 $93.56 $37.42 $18.71
93880.............. Extracranial study........ .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
93882.............. Extracranial study........ .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
93886.............. Intracranial study........ .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
93888.............. Intracranial study........ .................. S................. 0265 0.9570 $60.96 $22.35 $12.19
93890.............. Tcd, vasoreactivity study. .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
93892.............. Tcd, emboli detect w/o inj .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
93893.............. Tcd, emboli detect w/inj.. .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
93922.............. Extremity study........... .................. S................. 0096 1.4689 $93.56 $37.42 $18.71
93923.............. Extremity study........... .................. S................. 0096 1.4689 $93.56 $37.42 $18.71
93924.............. Extremity study........... .................. S................. 0096 1.4689 $93.56 $37.42 $18.71
93925.............. Lower extremity study..... .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
93926.............. Lower extremity study..... .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
93930.............. Upper extremity study..... .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
93931.............. Upper extremity study..... .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
93965.............. Extremity study........... .................. S................. 0096 1.4689 $93.56 $37.42 $18.71
93970.............. Extremity study........... .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
93971.............. Extremity study........... .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
93975.............. Vascular study............ .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
93976.............. Vascular study............ .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
93978.............. Vascular study............ CH................ S................. 0267 2.3792 $151.54 $60.50 $30.31
93979.............. Vascular study............ .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
93980.............. Penile vascular study..... .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
93981.............. Penile vascular study..... CH................ S................. 0267 2.3792 $151.54 $60.50 $30.31
93982.............. Aneurysm pressure sens NI................ X................. 0097 1.0015 $63.79 $23.79 $12.76
study.
93990.............. Doppler flow testing...... .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
94002.............. Vent mgmt inpat, init day. .................. S................. 0079 2.4783 $157.85 ........... $31.57
94003.............. Vent mgmt inpat, subq day. .................. S................. 0079 2.4783 $157.85 ........... $31.57
94004.............. Vent mgmt nf per day...... .................. B................. ........... ........... ........... ........... ...........
94005.............. Home vent mgmt supervision .................. B................. ........... ........... ........... ........... ...........
94010.............. Breathing capacity test... .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
94014.............. Patient recorded .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
spirometry.
94015.............. Patient recorded .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
spirometry.
94016.............. Review patient spirometry. .................. A................. ........... ........... ........... ........... ...........
94060.............. Evaluation of wheezing.... .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
94070.............. Evaluation of wheezing.... .................. X................. 0369 2.7550 $175.48 $44.18 $35.10
94150.............. Vital capacity test....... .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
94200.............. Lung function test (MBC/ .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
MVV).
94240.............. Residual lung capacity.... .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
94250.............. Expired gas collection.... .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
94260.............. Thoracic gas volume....... .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
94350.............. Lung nitrogen washout .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
curve.
94360.............. Measure airflow resistance .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
94370.............. Breath airway closing .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
volume.
94375.............. Respiratory flow volume CH................ X................. 0368 0.9253 $58.94 $22.77 $11.79
loop.
94400.............. CO2 breathing response .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
curve.
94450.............. Hypoxia response curve.... .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
94452.............. Hast w/report............. .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
94453.............. Hast w/oxygen titrate..... .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
94610.............. Surfactant admin thru tube .................. S................. 0077 0.3877 $24.69 $7.74 $4.94
94620.............. Pulmonary stress test/ .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
simple.
94621.............. Pulm stress test/complex.. .................. X................. 0369 2.7550 $175.48 $44.18 $35.10
94640.............. Airway inhalation .................. S................. 0077 0.3877 $24.69 $7.74 $4.94
treatment.
94642.............. Aerosol inhalation .................. S................. 0078 1.3362 $85.11 ........... $17.02
treatment.
94644.............. Cbt, 1st hour............. .................. S................. 0078 1.3362 $85.11 ........... $17.02
94645.............. Cbt, each addl hour....... .................. S................. 0078 1.3362 $85.11 ........... $17.02
94660.............. Pos airway pressure, CPAP. CH................ S................. 0078 1.3362 $85.11 ........... $17.02
94662.............. Neg press ventilation, cnp .................. S................. 0079 2.4783 $157.85 ........... $31.57
94664.............. Evaluate pt use of inhaler .................. S................. 0077 0.3877 $24.69 $7.74 $4.94
94667.............. Chest wall manipulation... .................. S................. 0077 0.3877 $24.69 $7.74 $4.94
94668.............. Chest wall manipulation... .................. S................. 0077 0.3877 $24.69 $7.74 $4.94
94680.............. Exhaled air analysis, o2.. CH................ X................. 0368 0.9253 $58.94 $22.77 $11.79
94681.............. Exhaled air analysis, o2/ .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
co2.
94690.............. Exhaled air analysis...... .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
[[Page 67102]]
94720.............. Monoxide diffusing .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
capacity.
94725.............. Membrane diffusion .................. X................. 0368 0.9253 $58.94 $22.77 $11.79
capacity.
94750.............. Pulmonary compliance study CH................ X................. 0368 0.9253 $58.94 $22.77 $11.79
94760.............. Measure blood oxygen level .................. N................. ........... ........... ........... ........... ...........
94761.............. Measure blood oxygen level .................. N................. ........... ........... ........... ........... ...........
94762.............. Measure blood oxygen level CH................ Q................. 0097 1.0015 $63.79 $23.79 $12.76
94770.............. Exhaled carbon dioxide .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
test.
94772.............. Breath recording, infant.. .................. X................. 0369 2.7550 $175.48 $44.18 $35.10
94774.............. Ped home apnea rec, compl. .................. B................. ........... ........... ........... ........... ...........
94775.............. Ped home apnea rec, hk-up. .................. X................. 0097 1.0015 $63.79 $23.79 $12.76
94776.............. Ped home apnea rec, downld .................. X................. 0097 1.0015 $63.79 $23.79 $12.76
94777.............. Ped home apnea rec, report .................. B................. ........... ........... ........... ........... ...........
94799.............. Pulmonary service/ .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
procedure.
95004.............. Percut allergy skin tests. .................. X................. 0381 0.2773 $17.66 ........... $3.53
95010.............. Percut allergy titrate .................. X................. 0381 0.2773 $17.66 ........... $3.53
test.
95012.............. Exhaled nitric oxide meas. .................. X................. 0367 0.5677 $36.16 $13.76 $7.23
95015.............. Id allergy titrate-drug/ .................. X................. 0381 0.2773 $17.66 ........... $3.53
bug.
95024.............. Id allergy test, drug/bug. .................. X................. 0381 0.2773 $17.66 ........... $3.53
95027.............. Id allergy titrate- .................. X................. 0381 0.2773 $17.66 ........... $3.53
airborne.
95028.............. Id allergy test-delayed .................. X................. 0381 0.2773 $17.66 ........... $3.53
type.
95044.............. Allergy patch tests....... .................. X................. 0381 0.2773 $17.66 ........... $3.53
95052.............. Photo patch test.......... .................. X................. 0381 0.2773 $17.66 ........... $3.53
95056.............. Photosensitivity tests.... .................. X................. 0370 1.0430 $66.43 ........... $13.29
95060.............. Eye allergy tests......... .................. X................. 0370 1.0430 $66.43 ........... $13.29
95065.............. Nose allergy test......... .................. X................. 0381 0.2773 $17.66 ........... $3.53
95070.............. Bronchial allergy tests... .................. X................. 0369 2.7550 $175.48 $44.18 $35.10
95071.............. Bronchial allergy tests... .................. X................. 0369 2.7550 $175.48 $44.18 $35.10
95075.............. Ingestion challenge test.. .................. X................. 0361 3.9276 $250.16 $83.23 $50.03
95115.............. Immunotherapy, one .................. S................. 0436 0.2545 $16.21 ........... $3.24
injection.
95117.............. Immunotherapy injections.. .................. S................. 0437 0.3945 $25.13 ........... $5.03
95120.............. Immunotherapy, one CH................ E................. ........... ........... ........... ........... ...........
injection.
95125.............. Immunotherapy, many CH................ E................. ........... ........... ........... ........... ...........
antigens.
95130.............. Immunotherapy, insect CH................ E................. ........... ........... ........... ........... ...........
venom.
95131.............. Immunotherapy, insect CH................ E................. ........... ........... ........... ........... ...........
venoms.
95132.............. Immunotherapy, insect CH................ E................. ........... ........... ........... ........... ...........
venoms.
95133.............. Immunotherapy, insect CH................ E................. ........... ........... ........... ........... ...........
venoms.
95134.............. Immunotherapy, insect CH................ E................. ........... ........... ........... ........... ...........
venoms.
95144.............. Antigen therapy services.. .................. S................. 0437 0.3945 $25.13 ........... $5.03
95145.............. Antigen therapy services.. .................. S................. 0437 0.3945 $25.13 ........... $5.03
95146.............. Antigen therapy services.. .................. S................. 0437 0.3945 $25.13 ........... $5.03
95147.............. Antigen therapy services.. .................. S................. 0437 0.3945 $25.13 ........... $5.03
95148.............. Antigen therapy services.. .................. S................. 0437 0.3945 $25.13 ........... $5.03
95149.............. Antigen therapy services.. .................. S................. 0437 0.3945 $25.13 ........... $5.03
95165.............. Antigen therapy services.. .................. S................. 0437 0.3945 $25.13 ........... $5.03
95170.............. Antigen therapy services.. .................. S................. 0437 0.3945 $25.13 ........... $5.03
95180.............. Rapid desensitization..... .................. X................. 0370 1.0430 $66.43 ........... $13.29
95199.............. Allergy immunology .................. X................. 0381 0.2773 $17.66 ........... $3.53
services.
95250.............. Glucose monitoring, cont.. CH................ V................. 0607 1.6604 $105.76 ........... $21.15
95251.............. Gluc monitor, cont, phys .................. B................. ........... ........... ........... ........... ...........
i&r.
95805.............. Multiple sleep latency .................. S................. 0209 11.2822 $718.61 $268.73 $143.72
test.
95806.............. Sleep study, unattended... .................. S................. 0213 2.2980 $146.37 $53.58 $29.27
95807.............. Sleep study, attended..... .................. S................. 0209 11.2822 $718.61 $268.73 $143.72
95808.............. Polysomnography, 1-3...... .................. S................. 0209 11.2822 $718.61 $268.73 $143.72
95810.............. Polysomnography, 4 or more .................. S................. 0209 11.2822 $718.61 $268.73 $143.72
95811.............. Polysomnography w/cpap.... .................. S................. 0209 11.2822 $718.61 $268.73 $143.72
95812.............. Eeg, 41-60 minutes........ .................. S................. 0213 2.2980 $146.37 $53.58 $29.27
95813.............. Eeg, over 1 hour.......... .................. S................. 0213 2.2980 $146.37 $53.58 $29.27
95816.............. Eeg, awake and drowsy..... .................. S................. 0213 2.2980 $146.37 $53.58 $29.27
95819.............. Eeg, awake and asleep..... .................. S................. 0213 2.2980 $146.37 $53.58 $29.27
95822.............. Eeg, coma or sleep only... .................. S................. 0213 2.2980 $146.37 $53.58 $29.27
95824.............. Eeg, cerebral death only.. CH................ S................. 0216 2.6846 $170.99 ........... $34.20
95827.............. Eeg, all night recording.. .................. S................. 0213 2.2980 $146.37 $53.58 $29.27
95829.............. Surgery electrocorticogram CH................ N................. ........... ........... ........... ........... ...........
95830.............. Insert electrodes for EEG. .................. B................. ........... ........... ........... ........... ...........
95831.............. Limb muscle testing, .................. A................. ........... ........... ........... ........... ...........
manual.
95832.............. Hand muscle testing, .................. A................. ........... ........... ........... ........... ...........
manual.
95833.............. Body muscle testing, .................. A................. ........... ........... ........... ........... ...........
manual.
95834.............. Body muscle testing, .................. A................. ........... ........... ........... ........... ...........
manual.
95851.............. Range of motion .................. A................. ........... ........... ........... ........... ...........
measurements.
95852.............. Range of motion .................. A................. ........... ........... ........... ........... ...........
measurements.
95857.............. Tensilon test............. .................. S................. 0218 1.1550 $73.57 ........... $14.71
95860.............. Muscle test, one limb..... .................. S................. 0218 1.1550 $73.57 ........... $14.71
95861.............. Muscle test, 2 limbs...... .................. S................. 0218 1.1550 $73.57 ........... $14.71
95863.............. Muscle test, 3 limbs...... .................. S................. 0218 1.1550 $73.57 ........... $14.71
95864.............. Muscle test, 4 limbs...... .................. S................. 0218 1.1550 $73.57 ........... $14.71
95865.............. Muscle test, larynx....... .................. S................. 0218 1.1550 $73.57 ........... $14.71
95866.............. Muscle test, hemidiaphragm .................. S................. 0218 1.1550 $73.57 ........... $14.71
95867.............. Muscle test cran nerv .................. S................. 0218 1.1550 $73.57 ........... $14.71
unilat.
95868.............. Muscle test cran nerve .................. S................. 0218 1.1550 $73.57 ........... $14.71
bilat.
95869.............. Muscle test, thor CH................ S................. 0218 1.1550 $73.57 ........... $14.71
paraspinal.
[[Page 67103]]
95870.............. Muscle test, nonparaspinal .................. S................. 0215 0.5804 $36.97 ........... $7.39
95872.............. Muscle test, one fiber.... .................. S................. 0218 1.1550 $73.57 ........... $14.71
95873.............. Guide nerv destr, elec CH................ N................. ........... ........... ........... ........... ...........
stim.
95874.............. Guide nerv destr, needle CH................ N................. ........... ........... ........... ........... ...........
emg.
95875.............. Limb exercise test........ .................. S................. 0215 0.5804 $36.97 ........... $7.39
95900.............. Motor nerve conduction .................. S................. 0215 0.5804 $36.97 ........... $7.39
test.
95903.............. Motor nerve conduction .................. S................. 0215 0.5804 $36.97 ........... $7.39
test.
95904.............. Sense nerve conduction .................. S................. 0215 0.5804 $36.97 ........... $7.39
test.
95920.............. Intraop nerve test add-on. CH................ N................. ........... ........... ........... ........... ...........
95921.............. Autonomic nerv function CH................ S................. 0218 1.1550 $73.57 ........... $14.71
test.
95922.............. Autonomic nerv function CH................ S................. 0218 1.1550 $73.57 ........... $14.71
test.
95923.............. Autonomic nerv function CH................ S................. 0218 1.1550 $73.57 ........... $14.71
test.
95925.............. Somatosensory testing..... .................. S................. 0216 2.6846 $170.99 ........... $34.20
95926.............. Somatosensory testing..... .................. S................. 0216 2.6846 $170.99 ........... $34.20
95927.............. Somatosensory testing..... .................. S................. 0216 2.6846 $170.99 ........... $34.20
95928.............. C motor evoked, uppr limbs .................. S................. 0218 1.1550 $73.57 ........... $14.71
95929.............. C motor evoked, lwr limbs. .................. S................. 0218 1.1550 $73.57 ........... $14.71
95930.............. Visual evoked potential .................. S................. 0216 2.6846 $170.99 ........... $34.20
test.
95933.............. Blink reflex test......... .................. S................. 0215 0.5804 $36.97 ........... $7.39
95934.............. H-reflex test............. .................. S................. 0215 0.5804 $36.97 ........... $7.39
95936.............. H-reflex test............. .................. S................. 0215 0.5804 $36.97 ........... $7.39
95937.............. Neuromuscular junction CH................ S................. 0218 1.1550 $73.57 ........... $14.71
test.
95950.............. Ambulatory eeg monitoring. .................. S................. 0209 11.2822 $718.61 $268.73 $143.72
95951.............. EEG monitoring/videorecord .................. S................. 0209 11.2822 $718.61 $268.73 $143.72
95953.............. EEG monitoring/computer... .................. S................. 0209 11.2822 $718.61 $268.73 $143.72
95954.............. EEG monitoring/giving CH................ S................. 0218 1.1550 $73.57 ........... $14.71
drugs.
95955.............. EEG during surgery........ CH................ N................. ........... ........... ........... ........... ...........
95956.............. Eeg monitoring, cable/ .................. S................. 0209 11.2822 $718.61 $268.73 $143.72
radio.
95957.............. EEG digital analysis...... CH................ N................. ........... ........... ........... ........... ...........
95958.............. EEG monitoring/function .................. S................. 0213 2.2980 $146.37 $53.58 $29.27
test.
95961.............. Electrode stimulation, .................. S................. 0216 2.6846 $170.99 ........... $34.20
brain.
95962.............. Electrode stim, brain add- .................. S................. 0216 2.6846 $170.99 ........... $34.20
on.
95965.............. Meg, spontaneous.......... CH................ S................. 0067 61.6965 $3,929.70 ........... $785.94
95966.............. Meg, evoked, single....... CH................ S................. 0065 16.5911 $1,056.75 ........... $211.35
95967.............. Meg, evoked, each add'l... CH................ S................. 0065 16.5911 $1,056.75 ........... $211.35
95970.............. Analyze neurostim, no prog .................. S................. 0218 1.1550 $73.57 ........... $14.71
95971.............. Analyze neurostim, simple. .................. S................. 0692 1.8376 $117.04 $29.72 $23.41
95972.............. Analyze neurostim, complex CH................ S................. 0663 1.5313 $97.53 ........... $19.51
95973.............. Analyze neurostim, complex .................. S................. 0663 1.5313 $97.53 ........... $19.51
95974.............. Cranial neurostim, complex CH................ S................. 0663 1.5313 $97.53 ........... $19.51
95975.............. Cranial neurostim, complex .................. S................. 0692 1.8376 $117.04 $29.72 $23.41
95978.............. Analyze neurostim brain/1h .................. S................. 0692 1.8376 $117.04 $29.72 $23.41
95979.............. Analyz neurostim brain .................. S................. 0663 1.5313 $97.53 ........... $19.51
addon.
95980.............. Io anal gast n-stim init.. NI................ N................. ........... ........... ........... ........... ...........
95981.............. Io anal gast n-stim subsq. NI................ S................. 0218 1.1550 $73.57 ........... $14.71
95982.............. Io ga n-stim subsq w/ NI................ S................. 0692 1.8376 $117.04 $29.72 $23.41
reprog.
95990.............. Spin/brain pump refil & .................. T................. 0125 2.3544 $149.96 ........... $29.99
main.
95991.............. Spin/brain pump refil & .................. T................. 0125 2.3544 $149.96 ........... $29.99
main.
95999.............. Neurological procedure.... .................. S................. 0215 0.5804 $36.97 ........... $7.39
96000.............. Motion analysis, video/3d. .................. S................. 0216 2.6846 $170.99 ........... $34.20
96001.............. Motion test w/ft press .................. S................. 0216 2.6846 $170.99 ........... $34.20
meas.
96002.............. Dynamic surface emg....... .................. S................. 0218 1.1550 $73.57 ........... $14.71
96003.............. Dynamic fine wire emg..... .................. S................. 0215 0.5804 $36.97 ........... $7.39
96004.............. Phys review of motion .................. B................. ........... ........... ........... ........... ...........
tests.
96020.............. Functional brain mapping.. CH................ N................. ........... ........... ........... ........... ...........
96040.............. Genetic counseling, 30 min .................. B................. ........... ........... ........... ........... ...........
96101.............. Psycho testing by psych/ CH................ Q................. 0382 2.6169 $166.68 ........... $33.34
phys.
96102.............. Psycho testing by CH................ Q................. 0382 2.6169 $166.68 ........... $33.34
technician.
96103.............. Psycho testing admin by CH................ Q................. 0373 1.2448 $79.29 ........... $15.86
comp.
96105.............. Assessment of aphasia..... .................. A................. ........... ........... ........... ........... ...........
96110.............. Developmental test, lim... CH................ Q................. 0373 1.2448 $79.29 ........... $15.86
96111.............. Developmental test, extend CH................ Q................. 0382 2.6169 $166.68 ........... $33.34
96116.............. Neurobehavioral status CH................ Q................. 0382 2.6169 $166.68 ........... $33.34
exam.
96118.............. Neuropsych tst by psych/ CH................ Q................. 0382 2.6169 $166.68 ........... $33.34
phys.
96119.............. Neuropsych testing by tec. CH................ Q................. 0382 2.6169 $166.68 ........... $33.34
96120.............. Neuropsych tst admin w/ CH................ Q................. 0373 1.2448 $79.29 ........... $15.86
comp.
96125.............. Cognitive test by hc pro.. NI................ A................. ........... ........... ........... ........... ...........
96150.............. Assess hlth/behave, init.. CH................ Q................. 0432 0.3128 $19.92 ........... $3.98
96151.............. Assess hlth/behave, subseq CH................ Q................. 0432 0.3128 $19.92 ........... $3.98
96152.............. Intervene hlth/behave, CH................ Q................. 0432 0.3128 $19.92 ........... $3.98
indiv.
96153.............. Intervene hlth/behave, CH................ Q................. 0432 0.3128 $19.92 ........... $3.98
group.
96154.............. Interv hlth/behav, fam w/ CH................ Q................. 0432 0.3128 $19.92 ........... $3.98
pt.
96155.............. Interv hlth/behav fam no .................. E................. ........... ........... ........... ........... ...........
pt.
96401.............. Chemo, anti-neopl, sq/im.. .................. S................. 0438 0.8041 $51.22 ........... $10.24
96402.............. Chemo hormon antineopl sq/ .................. S................. 0438 0.8041 $51.22 ........... $10.24
im.
96405.............. Chemo intralesional, up to .................. S................. 0438 0.8041 $51.22 ........... $10.24
7.
96406.............. Chemo intralesional over 7 .................. S................. 0438 0.8041 $51.22 ........... $10.24
96409.............. Chemo, iv push, sngl drug. .................. S................. 0439 1.6544 $105.38 ........... $21.08
96411.............. Chemo, iv push, addl drug. .................. S................. 0439 1.6544 $105.38 ........... $21.08
96413.............. Chemo, iv infusion, 1 hr.. .................. S................. 0441 2.3446 $149.34 ........... $29.87
[[Page 67104]]
96415.............. Chemo, iv infusion, addl .................. S................. 0438 0.8041 $51.22 ........... $10.24
hr.
96416.............. Chemo prolong infuse w/ .................. S................. 0441 2.3446 $149.34 ........... $29.87
pump.
96417.............. Chemo iv infus each addl .................. S................. 0438 0.8041 $51.22 ........... $10.24
seq.
96420.............. Chemo, ia, push tecnique.. .................. S................. 0439 1.6544 $105.38 ........... $21.08
96422.............. Chemo ia infusion up to 1 .................. S................. 0441 2.3446 $149.34 ........... $29.87
hr.
96423.............. Chemo ia infuse each addl .................. S................. 0438 0.8041 $51.22 ........... $10.24
hr.
96425.............. Chemotherapy,infusion .................. S................. 0441 2.3446 $149.34 ........... $29.87
method.
96440.............. Chemotherapy, .................. S................. 0441 2.3446 $149.34 ........... $29.87
intracavitary.
96445.............. Chemotherapy, .................. S................. 0441 2.3446 $149.34 ........... $29.87
intracavitary.
96450.............. Chemotherapy, into CNS.... .................. S................. 0441 2.3446 $149.34 ........... $29.87
96521.............. Refill/maint, portable .................. S................. 0440 1.7998 $114.64 ........... $22.93
pump.
96522.............. Refill/maint pump/resvr .................. S................. 0440 1.7998 $114.64 ........... $22.93
syst.
96523.............. Irrig drug delivery device .................. Q................. 0624 0.5689 $36.24 $12.65 $7.25
96542.............. Chemotherapy injection.... .................. S................. 0438 0.8041 $51.22 ........... $10.24
96549.............. Chemotherapy, unspecified. .................. S................. 0436 0.2545 $16.21 ........... $3.24
96567.............. Photodynamic tx, skin..... CH................ T................. 0013 0.7930 $50.51 ........... $10.10
96570.............. Photodynamic tx, 30 min... .................. T................. 0015 1.4595 $92.96 ........... $18.59
96571.............. Photodynamic tx, addl 15 .................. T................. 0015 1.4595 $92.96 ........... $18.59
min.
96900.............. Ultraviolet light therapy. .................. S................. 0001 0.4806 $30.61 $7.00 $6.12
96902.............. Trichogram................ .................. N................. ........... ........... ........... ........... ...........
96904.............. Whole body photography.... .................. N................. ........... ........... ........... ........... ...........
96910.............. Photochemotherapy with UV- .................. S................. 0001 0.4806 $30.61 $7.00 $6.12
B.
96912.............. Photochemotherapy with UV- .................. S................. 0001 0.4806 $30.61 $7.00 $6.12
A.
96913.............. Photochemotherapy, UV-A or .................. S................. 0683 2.6045 $165.89 ........... $33.18
B.
96920.............. Laser tx, skin < 250 sq cm CH................ T................. 0015 1.4595 $92.96 ........... $18.59
96921.............. Laser tx, skin 250-500 sq CH................ T................. 0015 1.4595 $92.96 ........... $18.59
cm.
96922.............. Laser tx, skin > 500 sq cm CH................ T................. 0015 1.4595 $92.96 ........... $18.59
96999.............. Dermatological procedure.. CH................ T................. 0012 0.2963 $18.87 ........... $3.77
97001.............. Pt evaluation............. .................. A................. ........... ........... ........... ........... ...........
97002.............. Pt re-evaluation.......... .................. A................. ........... ........... ........... ........... ...........
97003.............. Ot evaluation............. .................. A................. ........... ........... ........... ........... ...........
97004.............. Ot re-evaluation.......... .................. A................. ........... ........... ........... ........... ...........
97005.............. Athletic train eval....... .................. E................. ........... ........... ........... ........... ...........
97006.............. Athletic train reeval..... .................. E................. ........... ........... ........... ........... ...........
97010.............. Hot or cold packs therapy. .................. A................. ........... ........... ........... ........... ...........
97012.............. Mechanical traction .................. A................. ........... ........... ........... ........... ...........
therapy.
97014.............. Electric stimulation .................. E................. ........... ........... ........... ........... ...........
therapy.
97016.............. Vasopneumatic device .................. A................. ........... ........... ........... ........... ...........
therapy.
97018.............. Paraffin bath therapy..... .................. A................. ........... ........... ........... ........... ...........
97022.............. Whirlpool therapy......... .................. A................. ........... ........... ........... ........... ...........
97024.............. Diathermy eg, microwave... .................. A................. ........... ........... ........... ........... ...........
97026.............. Infrared therapy.......... .................. A................. ........... ........... ........... ........... ...........
97028.............. Ultraviolet therapy....... .................. A................. ........... ........... ........... ........... ...........
97032.............. Electrical stimulation.... .................. A................. ........... ........... ........... ........... ...........
97033.............. Electric current therapy.. .................. A................. ........... ........... ........... ........... ...........
97034.............. Contrast bath therapy..... .................. A................. ........... ........... ........... ........... ...........
97035.............. Ultrasound therapy........ .................. A................. ........... ........... ........... ........... ...........
97036.............. Hydrotherapy.............. .................. A................. ........... ........... ........... ........... ...........
97039.............. Physical therapy treatment .................. A................. ........... ........... ........... ........... ...........
97110.............. Therapeutic exercises..... .................. A................. ........... ........... ........... ........... ...........
97112.............. Neuromuscular reeducation. .................. A................. ........... ........... ........... ........... ...........
97113.............. Aquatic therapy/exercises. .................. A................. ........... ........... ........... ........... ...........
97116.............. Gait training therapy..... .................. A................. ........... ........... ........... ........... ...........
97124.............. Massage therapy........... .................. A................. ........... ........... ........... ........... ...........
97139.............. Physical medicine .................. A................. ........... ........... ........... ........... ...........
procedure.
97140.............. Manual therapy............ .................. A................. ........... ........... ........... ........... ...........
97150.............. Group therapeutic .................. A................. ........... ........... ........... ........... ...........
procedures.
97530.............. Therapeutic activities.... .................. A................. ........... ........... ........... ........... ...........
97532.............. Cognitive skills .................. A................. ........... ........... ........... ........... ...........
development.
97533.............. Sensory integration....... .................. A................. ........... ........... ........... ........... ...........
97535.............. Self care mngment training .................. A................. ........... ........... ........... ........... ...........
97537.............. Community/work .................. A................. ........... ........... ........... ........... ...........
reintegration.
97542.............. Wheelchair mngment .................. A................. ........... ........... ........... ........... ...........
training.
97545.............. Work hardening............ .................. A................. ........... ........... ........... ........... ...........
97546.............. Work hardening add-on..... .................. A................. ........... ........... ........... ........... ...........
97597.............. Active wound care/20 cm or CH................ T................. 0015 1.4595 $92.96 ........... $18.59
<.
97598.............. Active wound care > 20 cm. CH................ T................. 0015 1.4595 $92.96 ........... $18.59
97602.............. Wound(s) care non- CH................ T................. 0015 1.4595 $92.96 ........... $18.59
selective.
97605.............. Neg press wound tx, < 50 CH................ T................. 0013 0.7930 $50.51 ........... $10.10
cm.
97606.............. Neg press wound tx, > 50 CH................ T................. 0015 1.4595 $92.96 ........... $18.59
cm.
97750.............. Physical performance test. .................. A................. ........... ........... ........... ........... ...........
97755.............. Assistive technology .................. A................. ........... ........... ........... ........... ...........
assess.
97760.............. Orthotic mgmt and training .................. A................. ........... ........... ........... ........... ...........
97761.............. Prosthetic training....... .................. A................. ........... ........... ........... ........... ...........
97762.............. C/o for orthotic/prosth .................. A................. ........... ........... ........... ........... ...........
use.
97799.............. Physical medicine .................. A................. ........... ........... ........... ........... ...........
procedure.
97802.............. Medical nutrition, indiv, .................. A................. ........... ........... ........... ........... ...........
in.
97803.............. Med nutrition, indiv, .................. A................. ........... ........... ........... ........... ...........
subseq.
97804.............. Medical nutrition, group.. .................. A................. ........... ........... ........... ........... ...........
97810.............. Acupunct w/o stimul 15 min .................. E................. ........... ........... ........... ........... ...........
[[Page 67105]]
97811.............. Acupunct w/o stimul addl .................. E................. ........... ........... ........... ........... ...........
15m.
97813.............. Acupunct w/stimul 15 min.. .................. E................. ........... ........... ........... ........... ...........
97814.............. Acupunct w/stimul addl 15m .................. E................. ........... ........... ........... ........... ...........
98925.............. Osteopathic manipulation.. .................. S................. 0060 0.4482 $28.55 ........... $5.71
98926.............. Osteopathic manipulation.. .................. S................. 0060 0.4482 $28.55 ........... $5.71
98927.............. Osteopathic manipulation.. .................. S................. 0060 0.4482 $28.55 ........... $5.71
98928.............. Osteopathic manipulation.. .................. S................. 0060 0.4482 $28.55 ........... $5.71
98929.............. Osteopathic manipulation.. .................. S................. 0060 0.4482 $28.55 ........... $5.71
98940.............. Chiropractic manipulation. .................. S................. 0060 0.4482 $28.55 ........... $5.71
98941.............. Chiropractic manipulation. .................. S................. 0060 0.4482 $28.55 ........... $5.71
98942.............. Chiropractic manipulation. .................. S................. 0060 0.4482 $28.55 ........... $5.71
98943.............. Chiropractic manipulation. .................. E................. ........... ........... ........... ........... ...........
98960.............. Self-mgmt educ & train, 1 .................. E................. ........... ........... ........... ........... ...........
pt.
98961.............. Self-mgmt educ/train, 2-4 .................. E................. ........... ........... ........... ........... ...........
pt.
98962.............. Self-mgmt educ/train, 5-8 .................. E................. ........... ........... ........... ........... ...........
pt.
98966.............. Hc pro phone call 5-10 min NI................ E................. ........... ........... ........... ........... ...........
98967.............. Hc pro phone call 11-20 NI................ E................. ........... ........... ........... ........... ...........
min.
98968.............. Hc pro phone call 21-30 NI................ E................. ........... ........... ........... ........... ...........
min.
98969.............. Online service by hc pro.. NI................ E................. ........... ........... ........... ........... ...........
99000.............. Specimen handling......... .................. E................. ........... ........... ........... ........... ...........
99001.............. Specimen handling......... .................. E................. ........... ........... ........... ........... ...........
99002.............. Device handling........... .................. B................. ........... ........... ........... ........... ...........
99024.............. Postop follow-up visit.... .................. B................. ........... ........... ........... ........... ...........
99026.............. In-hospital on call .................. E................. ........... ........... ........... ........... ...........
service.
99027.............. Out-of-hosp on call .................. E................. ........... ........... ........... ........... ...........
service.
99050.............. Medical services after hrs .................. B................. ........... ........... ........... ........... ...........
99051.............. Med serv, eve/wkend/ .................. B................. ........... ........... ........... ........... ...........
holiday.
99053.............. Med serv 10pm-8am, 24 hr .................. B................. ........... ........... ........... ........... ...........
fac.
99056.............. Med service out of office. .................. B................. ........... ........... ........... ........... ...........
99058.............. Office emergency care..... .................. B................. ........... ........... ........... ........... ...........
99060.............. Out of office emerg med .................. B................. ........... ........... ........... ........... ...........
serv.
99070.............. Special supplies.......... .................. B................. ........... ........... ........... ........... ...........
99071.............. Patient education .................. B................. ........... ........... ........... ........... ...........
materials.
99075.............. Medical testimony......... .................. E................. ........... ........... ........... ........... ...........
99078.............. Group health education.... .................. N................. ........... ........... ........... ........... ...........
99080.............. Special reports or forms.. .................. B................. ........... ........... ........... ........... ...........
99082.............. Unusual physician travel.. .................. B................. ........... ........... ........... ........... ...........
99090.............. Computer data analysis.... .................. B................. ........... ........... ........... ........... ...........
99091.............. Collect/review data from .................. N................. ........... ........... ........... ........... ...........
pt.
99100.............. Special anesthesia service .................. B................. ........... ........... ........... ........... ...........
99116.............. Anesthesia with .................. B................. ........... ........... ........... ........... ...........
hypothermia.
99135.............. Special anesthesia .................. B................. ........... ........... ........... ........... ...........
procedure.
99140.............. Emergency anesthesia...... .................. B................. ........... ........... ........... ........... ...........
99143.............. Mod cs by same phys, < 5 .................. N................. ........... ........... ........... ........... ...........
yrs.
99144.............. Mod cs by same phys, 5 yrs .................. N................. ........... ........... ........... ........... ...........
+.
99145.............. Mod cs by same phys add-on .................. N................. ........... ........... ........... ........... ...........
99148.............. Mod cs diff phys < 5 yrs.. .................. N................. ........... ........... ........... ........... ...........
99149.............. Mod cs diff phys 5 yrs +.. .................. N................. ........... ........... ........... ........... ...........
99150.............. Mod cs diff phys add-on... .................. N................. ........... ........... ........... ........... ...........
99170.............. Anogenital exam, child.... .................. T................. 0191 0.1309 $8.34 $2.36 $1.67
99172.............. Ocular function screen.... .................. E................. ........... ........... ........... ........... ...........
99173.............. Visual acuity screen...... .................. E................. ........... ........... ........... ........... ...........
99174.............. Ocular photoscreening..... NI................ E................. ........... ........... ........... ........... ...........
99175.............. Induction of vomiting..... .................. N................. ........... ........... ........... ........... ...........
99183.............. Hyperbaric oxygen therapy. .................. B................. ........... ........... ........... ........... ...........
99185.............. Regional hypothermia...... .................. N................. ........... ........... ........... ........... ...........
99186.............. Total body hypothermia.... .................. N................. ........... ........... ........... ........... ...........
99190.............. Special pump services..... .................. C................. ........... ........... ........... ........... ...........
99191.............. Special pump services..... .................. C................. ........... ........... ........... ........... ...........
99192.............. Special pump services..... .................. C................. ........... ........... ........... ........... ...........
99195.............. Phlebotomy................ CH................ X................. 0624 0.5689 $36.24 $12.65 $7.25
99199.............. Special service/proc/ .................. B................. ........... ........... ........... ........... ...........
report.
99201.............. Office/outpatient visit, .................. V................. 0604 0.8388 $53.43 ........... $10.69
new.
99202.............. Office/outpatient visit, .................. V................. 0605 0.9964 $63.46 ........... $12.69
new.
99203.............. Office/outpatient visit, .................. V................. 0606 1.3226 $84.24 ........... $16.85
new.
99204.............. Office/outpatient visit, .................. V................. 0607 1.6604 $105.76 ........... $21.15
new.
99205.............. Office/outpatient visit, CH................ Q................. 0608 2.1740 $138.47 ........... $27.69
new.
99211.............. Office/outpatient visit, .................. V................. 0604 0.8388 $53.43 ........... $10.69
est.
99212.............. Office/outpatient visit, .................. V................. 0605 0.9964 $63.46 ........... $12.69
est.
99213.............. Office/outpatient visit, .................. V................. 0605 0.9964 $63.46 ........... $12.69
est.
99214.............. Office/outpatient visit, .................. V................. 0606 1.3226 $84.24 ........... $16.85
est.
99215.............. Office/outpatient visit, CH................ Q................. 0607 1.6604 $105.76 ........... $21.15
est.
99217.............. Observation care discharge .................. B................. ........... ........... ........... ........... ...........
99218.............. Observation care.......... .................. B................. ........... ........... ........... ........... ...........
99219.............. Observation care.......... .................. B................. ........... ........... ........... ........... ...........
99220.............. Observation care.......... .................. B................. ........... ........... ........... ........... ...........
99221.............. Initial hospital care..... .................. B................. ........... ........... ........... ........... ...........
99222.............. Initial hospital care..... .................. B................. ........... ........... ........... ........... ...........
99223.............. Initial hospital care..... .................. B................. ........... ........... ........... ........... ...........
99231.............. Subsequent hospital care.. .................. B................. ........... ........... ........... ........... ...........
[[Page 67106]]
99232.............. Subsequent hospital care.. .................. B................. ........... ........... ........... ........... ...........
99233.............. Subsequent hospital care.. .................. B................. ........... ........... ........... ........... ...........
99234.............. Observ/hosp same date..... .................. B................. ........... ........... ........... ........... ...........
99235.............. Observ/hosp same date..... .................. B................. ........... ........... ........... ........... ...........
99236.............. Observ/hosp same date..... .................. B................. ........... ........... ........... ........... ...........
99238.............. Hospital discharge day.... .................. B................. ........... ........... ........... ........... ...........
99239.............. Hospital discharge day.... .................. B................. ........... ........... ........... ........... ...........
99241.............. Office consultation....... CH................ B................. ........... ........... ........... ........... ...........
99242.............. Office consultation....... CH................ B................. ........... ........... ........... ........... ...........
99243.............. Office consultation....... CH................ B................. ........... ........... ........... ........... ...........
99244.............. Office consultation....... CH................ B................. ........... ........... ........... ........... ...........
99245.............. Office consultation....... CH................ B................. ........... ........... ........... ........... ...........
99251.............. Inpatient consultation.... .................. C................. ........... ........... ........... ........... ...........
99252.............. Inpatient consultation.... .................. C................. ........... ........... ........... ........... ...........
99253.............. Inpatient consultation.... .................. C................. ........... ........... ........... ........... ...........
99254.............. Inpatient consultation.... .................. C................. ........... ........... ........... ........... ...........
99255.............. Inpatient consultation.... .................. C................. ........... ........... ........... ........... ...........
99281.............. Emergency dept visit...... .................. V................. 0609 0.7970 $50.76 $12.70 $10.15
99282.............. Emergency dept visit...... .................. V................. 0613 1.3137 $83.67 $21.06 $16.73
99283.............. Emergency dept visit...... .................. V................. 0614 2.0750 $132.17 $34.50 $26.43
99284.............. Emergency dept visit...... CH................ Q................. 0615 3.3377 $212.59 $48.49 $42.52
99285.............. Emergency dept visit...... CH................ Q................. 0616 4.9535 $315.51 $72.86 $63.10
99288.............. Direct advanced life .................. B................. ........... ........... ........... ........... ...........
support.
99289.............. Ped crit care transport... .................. N................. ........... ........... ........... ........... ...........
99290.............. Ped crit care transport .................. N................. ........... ........... ........... ........... ...........
addl.
99291.............. Critical care, first hour. CH................ Q................. 0617 7.3166 $466.02 $111.59 $93.20
99292.............. Critical care, add'l 30 .................. N................. ........... ........... ........... ........... ...........
min.
99293.............. Ped critical care, initial .................. C................. ........... ........... ........... ........... ...........
99294.............. Ped critical care, subseq. .................. C................. ........... ........... ........... ........... ...........
99295.............. Neonate crit care, initial .................. C................. ........... ........... ........... ........... ...........
99296.............. Neonate critical care .................. C................. ........... ........... ........... ........... ...........
subseq.
99298.............. Ic for lbw infant < 1500 .................. C................. ........... ........... ........... ........... ...........
gm.
99299.............. Ic, lbw infant 1500-2500 .................. C................. ........... ........... ........... ........... ...........
gm.
99300.............. Ic, infant pbw 2501-5000 .................. N................. ........... ........... ........... ........... ...........
gm.
99304.............. Nursing facility care, .................. B................. ........... ........... ........... ........... ...........
init.
99305.............. Nursing facility care, .................. B................. ........... ........... ........... ........... ...........
init.
99306.............. Nursing facility care, .................. B................. ........... ........... ........... ........... ...........
init.
99307.............. Nursing fac care, subseq.. .................. B................. ........... ........... ........... ........... ...........
99308.............. Nursing fac care, subseq.. .................. B................. ........... ........... ........... ........... ...........
99309.............. Nursing fac care, subseq.. .................. B................. ........... ........... ........... ........... ...........
99310.............. Nursing fac care, subseq.. .................. B................. ........... ........... ........... ........... ...........
99315.............. Nursing fac discharge day. .................. B................. ........... ........... ........... ........... ...........
99316.............. Nursing fac discharge day. .................. B................. ........... ........... ........... ........... ...........
99318.............. Annual nursing fac .................. B................. ........... ........... ........... ........... ...........
assessmnt.
99324.............. Domicil/r-home visit new .................. B................. ........... ........... ........... ........... ...........
pat.
99325.............. Domicil/r-home visit new .................. B................. ........... ........... ........... ........... ...........
pat.
99326.............. Domicil/r-home visit new .................. B................. ........... ........... ........... ........... ...........
pat.
99327.............. Domicil/r-home visit new .................. B................. ........... ........... ........... ........... ...........
pat.
99328.............. Domicil/r-home visit new .................. B................. ........... ........... ........... ........... ...........
pat.
99334.............. Domicil/r-home visit est .................. B................. ........... ........... ........... ........... ...........
pat.
99335.............. Domicil/r-home visit est .................. B................. ........... ........... ........... ........... ...........
pat.
99336.............. Domicil/r-home visit est .................. B................. ........... ........... ........... ........... ...........
pat.
99337.............. Domicil/r-home visit est .................. B................. ........... ........... ........... ........... ...........
pat.
99339.............. Domicil/r-home care .................. B................. ........... ........... ........... ........... ...........
supervis.
99340.............. Domicil/r-home care .................. B................. ........... ........... ........... ........... ...........
supervis.
99341.............. Home visit, new patient... .................. B................. ........... ........... ........... ........... ...........
99342.............. Home visit, new patient... .................. B................. ........... ........... ........... ........... ...........
99343.............. Home visit, new patient... .................. B................. ........... ........... ........... ........... ...........
99344.............. Home visit, new patient... .................. B................. ........... ........... ........... ........... ...........
99345.............. Home visit, new patient... .................. B................. ........... ........... ........... ........... ...........
99347.............. Home visit, est patient... .................. B................. ........... ........... ........... ........... ...........
99348.............. Home visit, est patient... .................. B................. ........... ........... ........... ........... ...........
99349.............. Home visit, est patient... .................. B................. ........... ........... ........... ........... ...........
99350.............. Home visit, est patient... .................. B................. ........... ........... ........... ........... ...........
99354.............. Prolonged service, office. .................. N................. ........... ........... ........... ........... ...........
99355.............. Prolonged service, office. .................. N................. ........... ........... ........... ........... ...........
99356.............. Prolonged service, .................. C................. ........... ........... ........... ........... ...........
inpatient.
99357.............. Prolonged service, .................. C................. ........... ........... ........... ........... ...........
inpatient.
99358.............. Prolonged serv, w/o .................. N................. ........... ........... ........... ........... ...........
contact.
99359.............. Prolonged serv, w/o .................. N................. ........... ........... ........... ........... ...........
contact.
99360.............. Physician standby services .................. B................. ........... ........... ........... ........... ...........
99361.............. Physician/team conference. CH................ D................. ........... ........... ........... ........... ...........
99362.............. Physician/team conference. CH................ D................. ........... ........... ........... ........... ...........
99363.............. Anticoag mgmt, init....... .................. B................. ........... ........... ........... ........... ...........
99364.............. Anticoag mgmt, subseq..... .................. B................. ........... ........... ........... ........... ...........
99366.............. Team conf w/pat by hc pro. NI................ N................. ........... ........... ........... ........... ...........
99367.............. Team conf w/o pat by phys. NI................ N................. ........... ........... ........... ........... ...........
99368.............. Team conf w/o pat by hc NI................ N................. ........... ........... ........... ........... ...........
pro.
99371.............. Physician phone CH................ D................. ........... ........... ........... ........... ...........
consultation.
99372.............. Physician phone CH................ D................. ........... ........... ........... ........... ...........
consultation.
[[Page 67107]]
99373.............. Physician phone CH................ D................. ........... ........... ........... ........... ...........
consultation.
99374.............. Home health care .................. B................. ........... ........... ........... ........... ...........
supervision.
99375.............. Home health care .................. E................. ........... ........... ........... ........... ...........
supervision.
99377.............. Hospice care supervision.. .................. B................. ........... ........... ........... ........... ...........
99378.............. Hospice care supervision.. .................. E................. ........... ........... ........... ........... ...........
99379.............. Nursing fac care .................. B................. ........... ........... ........... ........... ...........
supervision.
99380.............. Nursing fac care .................. B................. ........... ........... ........... ........... ...........
supervision.
99381.............. Init pm e/m, new pat, inf. .................. E................. ........... ........... ........... ........... ...........
99382.............. Init pm e/m, new pat 1-4 .................. E................. ........... ........... ........... ........... ...........
yrs.
99383.............. Prev visit, new, age 5-11. .................. E................. ........... ........... ........... ........... ...........
99384.............. Prev visit, new, age 12-17 .................. E................. ........... ........... ........... ........... ...........
99385.............. Prev visit, new, age 18-39 .................. E................. ........... ........... ........... ........... ...........
99386.............. Prev visit, new, age 40-64 .................. E................. ........... ........... ........... ........... ...........
99387.............. Init pm e/m, new pat 65+ .................. E................. ........... ........... ........... ........... ...........
yrs.
99391.............. Per pm reeval, est pat, .................. E................. ........... ........... ........... ........... ...........
inf.
99392.............. Prev visit, est, age 1-4.. .................. E................. ........... ........... ........... ........... ...........
99393.............. Prev visit, est, age 5-11. .................. E................. ........... ........... ........... ........... ...........
99394.............. Prev visit, est, age 12-17 .................. E................. ........... ........... ........... ........... ...........
99395.............. Prev visit, est, age 18-39 .................. E................. ........... ........... ........... ........... ...........
99396.............. Prev visit, est, age 40-64 .................. E................. ........... ........... ........... ........... ...........
99397.............. Per pm reeval est pat 65+ .................. E................. ........... ........... ........... ........... ...........
yr.
99401.............. Preventive counseling, .................. E................. ........... ........... ........... ........... ...........
indiv.
99402.............. Preventive counseling, .................. E................. ........... ........... ........... ........... ...........
indiv.
99403.............. Preventive counseling, .................. E................. ........... ........... ........... ........... ...........
indiv.
99404.............. Preventive counseling, .................. E................. ........... ........... ........... ........... ...........
indiv.
99406.............. Behav chng smoking 3-10 NI................ X................. 0031 0.1648 $10.50 ........... $2.10
min.
99407.............. Behav chng smoking < 10 NI................ X................. 0031 0.1648 $10.50 ........... $2.10
min.
99408.............. Audit/dast, 15-30 min..... NI................ E................. ........... ........... ........... ........... ...........
99409.............. Audit/dast, over 30 min... NI................ E................. ........... ........... ........... ........... ...........
99411.............. Preventive counseling, .................. E................. ........... ........... ........... ........... ...........
group.
99412.............. Preventive counseling, .................. E................. ........... ........... ........... ........... ...........
group.
99420.............. Health risk assessment .................. E................. ........... ........... ........... ........... ...........
test.
99429.............. Unlisted preventive .................. E................. ........... ........... ........... ........... ...........
service.
99431.............. Initial care, normal .................. V................. 0605 0.9964 $63.46 ........... $12.69
newborn.
99432.............. Newborn care, not in hosp. .................. N................. ........... ........... ........... ........... ...........
99433.............. Normal newborn care/ .................. C................. ........... ........... ........... ........... ...........
hospital.
99435.............. Newborn discharge day hosp .................. B................. ........... ........... ........... ........... ...........
99436.............. Attendance, birth......... .................. N................. ........... ........... ........... ........... ...........
99440.............. Newborn resuscitation..... .................. S................. 0094 2.4590 $156.62 $46.29 $31.32
99441.............. Phone e/m by phys 5-10 min NI................ E................. ........... ........... ........... ........... ...........
99442.............. Phone e/m by phys 11-20 NI................ E................. ........... ........... ........... ........... ...........
min.
99443.............. Phone e/m by phys 21-30 NI................ E................. ........... ........... ........... ........... ...........
min.
99444.............. Online e/m by phys........ NI................ E................. ........... ........... ........... ........... ...........
99450.............. Basic life disability exam .................. E................. ........... ........... ........... ........... ...........
99455.............. Work related disability .................. B................. ........... ........... ........... ........... ...........
exam.
99456.............. Disability examination.... .................. B................. ........... ........... ........... ........... ...........
99477.............. Init day hosp neonate care NI................ C................. ........... ........... ........... ........... ...........
99499.............. Unlisted e&m service...... .................. B................. ........... ........... ........... ........... ...........
99500.............. Home visit, prenatal...... .................. E................. ........... ........... ........... ........... ...........
99501.............. Home visit, postnatal..... .................. E................. ........... ........... ........... ........... ...........
99502.............. Home visit, nb care....... .................. E................. ........... ........... ........... ........... ...........
99503.............. Home visit, resp therapy.. .................. E................. ........... ........... ........... ........... ...........
99504.............. Home visit mech ventilator .................. E................. ........... ........... ........... ........... ...........
99505.............. Home visit, stoma care.... .................. E................. ........... ........... ........... ........... ...........
99506.............. Home visit, im injection.. .................. E................. ........... ........... ........... ........... ...........
99507.............. Home visit, cath maintain. .................. E................. ........... ........... ........... ........... ...........
99509.............. Home visit day life .................. E................. ........... ........... ........... ........... ...........
activity.
99510.............. Home visit, sing/m/fam .................. E................. ........... ........... ........... ........... ...........
couns.
99511.............. Home visit, fecal/enema .................. E................. ........... ........... ........... ........... ...........
mgmt.
99512.............. Home visit for .................. E................. ........... ........... ........... ........... ...........
hemodialysis.
99600.............. Home visit nos............ .................. E................. ........... ........... ........... ........... ...........
99601.............. Home infusion/visit, 2 hrs .................. E................. ........... ........... ........... ........... ...........
99602.............. Home infusion, each addtl .................. E................. ........... ........... ........... ........... ...........
hr.
99605.............. Mtms by pharm, np, 15 min. NI................ E................. ........... ........... ........... ........... ...........
99606.............. Mtms by pharm, est, 15 min NI................ E................. ........... ........... ........... ........... ...........
99607.............. Mtms by pharm, addl 15 min NI................ E................. ........... ........... ........... ........... ...........
A0021.............. Outside state ambulance .................. E................. ........... ........... ........... ........... ...........
serv.
A0080.............. Noninterest escort in non .................. E................. ........... ........... ........... ........... ...........
er.
A0090.............. Interest escort in non er. .................. E................. ........... ........... ........... ........... ...........
A0100.............. Nonemergency transport .................. E................. ........... ........... ........... ........... ...........
taxi.
A0110.............. Nonemergency transport bus .................. E................. ........... ........... ........... ........... ...........
A0120.............. Noner transport mini-bus.. .................. E................. ........... ........... ........... ........... ...........
A0130.............. Noner transport wheelch .................. E................. ........... ........... ........... ........... ...........
van.
A0140.............. Nonemergency transport air .................. E................. ........... ........... ........... ........... ...........
A0160.............. Noner transport case .................. E................. ........... ........... ........... ........... ...........
worker.
A0170.............. Transport parking fees/ .................. E................. ........... ........... ........... ........... ...........
tolls.
A0180.............. Noner transport lodgng .................. E................. ........... ........... ........... ........... ...........
recip.
A0190.............. Noner transport meals .................. E................. ........... ........... ........... ........... ...........
recip.
A0200.............. Noner transport lodgng .................. E................. ........... ........... ........... ........... ...........
escrt.
A0210.............. Noner transport meals .................. E................. ........... ........... ........... ........... ...........
escort.
[[Page 67108]]
A0225.............. Neonatal emergency CH................ E................. ........... ........... ........... ........... ...........
transport.
A0380.............. Basic life support mileage CH................ E................. ........... ........... ........... ........... ...........
A0382.............. Basic support routine .................. A................. ........... ........... ........... ........... ...........
suppls.
A0384.............. Bls defibrillation .................. A................. ........... ........... ........... ........... ...........
supplies.
A0390.............. Advanced life support CH................ E................. ........... ........... ........... ........... ...........
mileag.
A0392.............. Als defibrillation .................. A................. ........... ........... ........... ........... ...........
supplies.
A0394.............. Als IV drug therapy .................. A................. ........... ........... ........... ........... ...........
supplies.
A0396.............. Als esophageal intub .................. A................. ........... ........... ........... ........... ...........
suppls.
A0398.............. Als routine disposble .................. A................. ........... ........... ........... ........... ...........
suppls.
A0420.............. Ambulance waiting 1/2 hr.. .................. A................. ........... ........... ........... ........... ...........
A0422.............. Ambulance 02 life .................. A................. ........... ........... ........... ........... ...........
sustaining.
A0424.............. Extra ambulance attendant. .................. A................. ........... ........... ........... ........... ...........
A0425.............. Ground mileage............ .................. A................. ........... ........... ........... ........... ...........
A0426.............. Als 1..................... .................. A................. ........... ........... ........... ........... ...........
A0427.............. ALS1-emergency............ .................. A................. ........... ........... ........... ........... ...........
A0428.............. bls....................... .................. A................. ........... ........... ........... ........... ...........
A0429.............. BLS-emergency............. .................. A................. ........... ........... ........... ........... ...........
A0430.............. Fixed wing air transport.. .................. A................. ........... ........... ........... ........... ...........
A0431.............. Rotary wing air transport. .................. A................. ........... ........... ........... ........... ...........
A0432.............. PI volunteer ambulance co. .................. A................. ........... ........... ........... ........... ...........
A0433.............. als 2..................... .................. A................. ........... ........... ........... ........... ...........
A0434.............. Specialty care transport.. .................. A................. ........... ........... ........... ........... ...........
A0435.............. Fixed wing air mileage.... .................. A................. ........... ........... ........... ........... ...........
A0436.............. Rotary wing air mileage... .................. A................. ........... ........... ........... ........... ...........
A0888.............. Noncovered ambulance .................. E................. ........... ........... ........... ........... ...........
mileage.
A0998.............. Ambulance response/ .................. E................. ........... ........... ........... ........... ...........
treatment.
A0999.............. Unlisted ambulance service .................. A................. ........... ........... ........... ........... ...........
A4206.............. 1 CC sterile .................. E................. ........... ........... ........... ........... ...........
syringe&needle.
A4207.............. 2 CC sterile .................. E................. ........... ........... ........... ........... ...........
syringe&needle.
A4208.............. 3 CC sterile .................. E................. ........... ........... ........... ........... ...........
syringe&needle.
A4209.............. 5+ CC sterile .................. E................. ........... ........... ........... ........... ...........
syringe&needle.
A4210.............. Nonneedle injection device .................. E................. ........... ........... ........... ........... ...........
A4211.............. Supp for self-adm .................. E................. ........... ........... ........... ........... ...........
injections.
A4212.............. Non coring needle or .................. B................. ........... ........... ........... ........... ...........
stylet.
A4213.............. 20+ CC syringe only....... .................. E................. ........... ........... ........... ........... ...........
A4215.............. Sterile needle............ .................. E................. ........... ........... ........... ........... ...........
A4216.............. Sterile water/saline, 10 .................. A................. ........... ........... ........... ........... ...........
ml.
A4217.............. Sterile water/saline, 500 .................. A................. ........... ........... ........... ........... ...........
ml.
A4218.............. Sterile saline or water... .................. N................. ........... ........... ........... ........... ...........
A4220.............. Infusion pump refill kit.. .................. N................. ........... ........... ........... ........... ...........
A4221.............. Maint drug infus cath per .................. Y................. ........... ........... ........... ........... ...........
wk.
A4222.............. Infusion supplies with .................. Y................. ........... ........... ........... ........... ...........
pump.
A4223.............. Infusion supplies w/o pump .................. E................. ........... ........... ........... ........... ...........
A4230.............. Infus insulin pump non .................. Y................. ........... ........... ........... ........... ...........
needl.
A4231.............. Infusion insulin pump .................. Y................. ........... ........... ........... ........... ...........
needle.
A4232.............. Syringe w/needle insulin .................. E................. ........... ........... ........... ........... ...........
3cc.
A4233.............. Alkalin batt for glucose .................. Y................. ........... ........... ........... ........... ...........
mon.
A4234.............. J-cell batt for glucose .................. Y................. ........... ........... ........... ........... ...........
mon.
A4235.............. Lithium batt for glucose .................. Y................. ........... ........... ........... ........... ...........
mon.
A4236.............. Silvr oxide batt glucose .................. Y................. ........... ........... ........... ........... ...........
mon.
A4244.............. Alcohol or peroxide per .................. E................. ........... ........... ........... ........... ...........
pint.
A4245.............. Alcohol wipes per box..... .................. E................. ........... ........... ........... ........... ...........
A4246.............. Betadine/phisohex solution .................. E................. ........... ........... ........... ........... ...........
A4247.............. Betadine/iodine swabs/ .................. E................. ........... ........... ........... ........... ...........
wipes.
A4248.............. Chlorhexidine antisept.... .................. N................. ........... ........... ........... ........... ...........
A4250.............. Urine reagent strips/ .................. E................. ........... ........... ........... ........... ...........
tablets.
A4252.............. Blood ketone test or strip NI................ E................. ........... ........... ........... ........... ...........
A4253.............. Blood glucose/reagent .................. Y................. ........... ........... ........... ........... ...........
strips.
A4255.............. Glucose monitor platforms. .................. Y................. ........... ........... ........... ........... ...........
A4256.............. Calibrator solution/chips. .................. Y................. ........... ........... ........... ........... ...........
A4257.............. Replace Lensshield .................. Y................. ........... ........... ........... ........... ...........
Cartridge.
A4258.............. Lancet device each........ .................. Y................. ........... ........... ........... ........... ...........
A4259.............. Lancets per box........... .................. Y................. ........... ........... ........... ........... ...........
A4261.............. Cervical cap contraceptive .................. E................. ........... ........... ........... ........... ...........
A4262.............. Temporary tear duct plug.. .................. N................. ........... ........... ........... ........... ...........
A4263.............. Permanent tear duct plug.. .................. N................. ........... ........... ........... ........... ...........
A4265.............. Paraffin.................. .................. Y................. ........... ........... ........... ........... ...........
A4266.............. Diaphragm................. .................. E................. ........... ........... ........... ........... ...........
A4267.............. Male condom............... .................. E................. ........... ........... ........... ........... ...........
A4268.............. Female condom............. .................. E................. ........... ........... ........... ........... ...........
A4269.............. Spermicide................ .................. E................. ........... ........... ........... ........... ...........
A4270.............. Disposable endoscope .................. N................. ........... ........... ........... ........... ...........
sheath.
A4280.............. Brst prsths adhsv attchmnt .................. A................. ........... ........... ........... ........... ...........
A4281.............. Replacement breastpump .................. E................. ........... ........... ........... ........... ...........
tube.
A4282.............. Replacement breastpump .................. E................. ........... ........... ........... ........... ...........
adpt.
A4283.............. Replacement breastpump cap .................. E................. ........... ........... ........... ........... ...........
A4284.............. Replcmnt breast pump .................. E................. ........... ........... ........... ........... ...........
shield.
A4285.............. Replcmnt breast pump .................. E................. ........... ........... ........... ........... ...........
bottle.
A4286.............. Replcmnt breastpump lok .................. E................. ........... ........... ........... ........... ...........
ring.
A4290.............. Sacral nerve stim test .................. B................. ........... ........... ........... ........... ...........
lead.
[[Page 67109]]
A4300.............. Cath impl vasc access .................. N................. ........... ........... ........... ........... ...........
portal.
A4301.............. Implantable access syst .................. N................. ........... ........... ........... ........... ...........
perc.
A4305.............. Drug delivery system >=50 .................. N................. ........... ........... ........... ........... ...........
ML.
A4306.............. Drug delivery system <=50 .................. N................. ........... ........... ........... ........... ...........
ml.
A4310.............. Insert tray w/o bag/cath.. .................. A................. ........... ........... ........... ........... ...........
A4311.............. Catheter w/o bag 2-way .................. A................. ........... ........... ........... ........... ...........
latex.
A4312.............. Cath w/o bag 2-way .................. A................. ........... ........... ........... ........... ...........
silicone.
A4313.............. Catheter w/bag 3-way...... .................. A................. ........... ........... ........... ........... ...........
A4314.............. Cath w/drainage 2-way .................. A................. ........... ........... ........... ........... ...........
latex.
A4315.............. Cath w/drainage 2-way .................. A................. ........... ........... ........... ........... ...........
silcne.
A4316.............. Cath w/drainage 3-way..... .................. A................. ........... ........... ........... ........... ...........
A4320.............. Irrigation tray........... .................. A................. ........... ........... ........... ........... ...........
A4321.............. Cath therapeutic irrig .................. A................. ........... ........... ........... ........... ...........
agent.
A4322.............. Irrigation syringe........ .................. A................. ........... ........... ........... ........... ...........
A4326.............. Male external catheter.... .................. A................. ........... ........... ........... ........... ...........
A4327.............. Fem urinary collect dev .................. A................. ........... ........... ........... ........... ...........
cup.
A4328.............. Fem urinary collect pouch. .................. A................. ........... ........... ........... ........... ...........
A4330.............. Stool collection pouch.... .................. A................. ........... ........... ........... ........... ...........
A4331.............. Extension drainage tubing. .................. A................. ........... ........... ........... ........... ...........
A4332.............. Lube sterile packet....... .................. A................. ........... ........... ........... ........... ...........
A4333.............. Urinary cath anchor device .................. A................. ........... ........... ........... ........... ...........
A4334.............. Urinary cath leg strap.... .................. A................. ........... ........... ........... ........... ...........
A4335.............. Incontinence supply....... .................. A................. ........... ........... ........... ........... ...........
A4338.............. Indwelling catheter latex. .................. A................. ........... ........... ........... ........... ...........
A4340.............. Indwelling catheter .................. A................. ........... ........... ........... ........... ...........
special.
A4344.............. Cath indw foley 2 way .................. A................. ........... ........... ........... ........... ...........
silicn.
A4346.............. Cath indw foley 3 way..... .................. A................. ........... ........... ........... ........... ...........
A4349.............. Disposable male external .................. A................. ........... ........... ........... ........... ...........
cat.
A4351.............. Straight tip urine .................. A................. ........... ........... ........... ........... ...........
catheter.
A4352.............. Coude tip urinary catheter .................. A................. ........... ........... ........... ........... ...........
A4353.............. Intermittent urinary cath. .................. A................. ........... ........... ........... ........... ...........
A4354.............. Cath insertion tray w/bag. .................. A................. ........... ........... ........... ........... ...........
A4355.............. Bladder irrigation tubing. .................. A................. ........... ........... ........... ........... ...........
A4356.............. Ext ureth clmp or compr .................. A................. ........... ........... ........... ........... ...........
dvc.
A4357.............. Bedside drainage bag...... .................. A................. ........... ........... ........... ........... ...........
A4358.............. Urinary leg or abdomen bag .................. A................. ........... ........... ........... ........... ...........
A4361.............. Ostomy face plate......... .................. A................. ........... ........... ........... ........... ...........
A4362.............. Solid skin barrier........ .................. A................. ........... ........... ........... ........... ...........
A4363.............. Ostomy clamp, replacement. .................. A................. ........... ........... ........... ........... ...........
A4364.............. Adhesive, liquid or equal. .................. A................. ........... ........... ........... ........... ...........
A4365.............. Adhesive remover wipes.... .................. A................. ........... ........... ........... ........... ...........
A4366.............. Ostomy vent............... .................. A................. ........... ........... ........... ........... ...........
A4367.............. Ostomy belt............... .................. A................. ........... ........... ........... ........... ...........
A4368.............. Ostomy filter............. .................. A................. ........... ........... ........... ........... ...........
A4369.............. Skin barrier liquid per oz .................. A................. ........... ........... ........... ........... ...........
A4371.............. Skin barrier powder per oz .................. A................. ........... ........... ........... ........... ...........
A4372.............. Skin barrier solid 4x4 .................. A................. ........... ........... ........... ........... ...........
equiv.
A4373.............. Skin barrier with flange.. .................. A................. ........... ........... ........... ........... ...........
A4375.............. Drainable plastic pch w .................. A................. ........... ........... ........... ........... ...........
fcpl.
A4376.............. Drainable rubber pch w .................. A................. ........... ........... ........... ........... ...........
fcplt.
A4377.............. Drainable plstic pch w/o .................. A................. ........... ........... ........... ........... ...........
fp.
A4378.............. Drainable rubber pch w/o .................. A................. ........... ........... ........... ........... ...........
fp.
A4379.............. Urinary plastic pouch w .................. A................. ........... ........... ........... ........... ...........
fcpl.
A4380.............. Urinary rubber pouch w .................. A................. ........... ........... ........... ........... ...........
fcplt.
A4381.............. Urinary plastic pouch w/o .................. A................. ........... ........... ........... ........... ...........
fp.
A4382.............. Urinary hvy plstc pch w/o .................. A................. ........... ........... ........... ........... ...........
fp.
A4383.............. Urinary rubber pouch w/o .................. A................. ........... ........... ........... ........... ...........
fp.
A4384.............. Ostomy faceplt/silicone .................. A................. ........... ........... ........... ........... ...........
ring.
A4385.............. Ost skn barrier sld ext .................. A................. ........... ........... ........... ........... ...........
wear.
A4387.............. Ost clsd pouch w att st .................. A................. ........... ........... ........... ........... ...........
barr.
A4388.............. Drainable pch w ex wear .................. A................. ........... ........... ........... ........... ...........
barr.
A4389.............. Drainable pch w st wear .................. A................. ........... ........... ........... ........... ...........
barr.
A4390.............. Drainable pch ex wear .................. A................. ........... ........... ........... ........... ...........
convex.
A4391.............. Urinary pouch w ex wear .................. A................. ........... ........... ........... ........... ...........
barr.
A4392.............. Urinary pouch w st wear .................. A................. ........... ........... ........... ........... ...........
barr.
A4393.............. Urine pch w ex wear bar .................. A................. ........... ........... ........... ........... ...........
conv.
A4394.............. Ostomy pouch liq deodorant .................. A................. ........... ........... ........... ........... ...........
A4395.............. Ostomy pouch solid .................. A................. ........... ........... ........... ........... ...........
deodorant.
A4396.............. Peristomal hernia supprt .................. A................. ........... ........... ........... ........... ...........
blt.
A4397.............. Irrigation supply sleeve.. .................. A................. ........... ........... ........... ........... ...........
A4398.............. Ostomy irrigation bag..... .................. A................. ........... ........... ........... ........... ...........
A4399.............. Ostomy irrig cone/cath w .................. A................. ........... ........... ........... ........... ...........
brs.
A4400.............. Ostomy irrigation set..... .................. A................. ........... ........... ........... ........... ...........
A4402.............. Lubricant per ounce....... .................. A................. ........... ........... ........... ........... ...........
A4404.............. Ostomy ring each.......... .................. A................. ........... ........... ........... ........... ...........
A4405.............. Nonpectin based ostomy .................. A................. ........... ........... ........... ........... ...........
paste.
A4406.............. Pectin based ostomy paste. .................. A................. ........... ........... ........... ........... ...........
A4407.............. Ext wear ost skn barr .................. A................. ........... ........... ........... ........... ...........
<=4sq*.
A4408.............. Ext wear ost skn barr >4sq .................. A................. ........... ........... ........... ........... ...........
A4409.............. Ost skn barr convex <=4 sq .................. A................. ........... ........... ........... ........... ...........
i.
[[Page 67110]]
A4410.............. Ost skn barr extnd >4 sq.. .................. A................. ........... ........... ........... ........... ...........
A4411.............. Ost skn barr extnd =4sq... .................. A................. ........... ........... ........... ........... ...........
A4412.............. Ost pouch drain high .................. A................. ........... ........... ........... ........... ...........
output.
A4413.............. 2 pc drainable ost pouch.. .................. A................. ........... ........... ........... ........... ...........
A4414.............. Ost sknbar w/o conv<=4 sq .................. A................. ........... ........... ........... ........... ...........
in.
A4415.............. Ost skn barr w/o conv >4 .................. A................. ........... ........... ........... ........... ...........
sqi.
A4416.............. Ost pch clsd w barrier/ .................. A................. ........... ........... ........... ........... ...........
filtr.
A4417.............. Ost pch w bar/bltinconv/ .................. A................. ........... ........... ........... ........... ...........
fltr.
A4418.............. Ost pch clsd w/o bar w .................. A................. ........... ........... ........... ........... ...........
filtr.
A4419.............. Ost pch for bar w flange/ .................. A................. ........... ........... ........... ........... ...........
flt.
A4420.............. Ost pch clsd for bar w lk .................. A................. ........... ........... ........... ........... ...........
fl.
A4421.............. Ostomy supply misc........ .................. E................. ........... ........... ........... ........... ...........
A4422.............. Ost pouch absorbent .................. A................. ........... ........... ........... ........... ...........
material.
A4423.............. Ost pch for bar w lk fl/ .................. A................. ........... ........... ........... ........... ...........
fltr.
A4424.............. Ost pch drain w bar & .................. A................. ........... ........... ........... ........... ...........
filter.
A4425.............. Ost pch drain for barrier .................. A................. ........... ........... ........... ........... ...........
fl.
A4426.............. Ost pch drain 2 piece .................. A................. ........... ........... ........... ........... ...........
system.
A4427.............. Ost pch drain/barr lk flng/ .................. A................. ........... ........... ........... ........... ...........
f.
A4428.............. Urine ost pouch w faucet/ .................. A................. ........... ........... ........... ........... ...........
tap.
A4429.............. Urine ost pouch w .................. A................. ........... ........... ........... ........... ...........
bltinconv.
A4430.............. Ost urine pch w b/bltin .................. A................. ........... ........... ........... ........... ...........
conv.
A4431.............. Ost pch urine w barrier/ .................. A................. ........... ........... ........... ........... ...........
tapv.
A4432.............. Os pch urine w bar/fange/ .................. A................. ........... ........... ........... ........... ...........
tap.
A4433.............. Urine ost pch bar w lock .................. A................. ........... ........... ........... ........... ...........
fln.
A4434.............. Ost pch urine w lock flng/ .................. A................. ........... ........... ........... ........... ...........
ft.
A4450.............. Non-waterproof tape....... .................. A................. ........... ........... ........... ........... ...........
A4452.............. Waterproof tape........... .................. A................. ........... ........... ........... ........... ...........
A4455.............. Adhesive remover per ounce .................. A................. ........... ........... ........... ........... ...........
A4458.............. Reusable enema bag........ .................. E................. ........... ........... ........... ........... ...........
A4461.............. Surgicl dress hold non- .................. A................. ........... ........... ........... ........... ...........
reuse.
A4463.............. Surgical dress holder .................. A................. ........... ........... ........... ........... ...........
reuse.
A4465.............. Non-elastic extremity .................. A................. ........... ........... ........... ........... ...........
binder.
A4470.............. Gravlee jet washer........ .................. A................. ........... ........... ........... ........... ...........
A4480.............. Vabra aspirator........... .................. A................. ........... ........... ........... ........... ...........
A4481.............. Tracheostoma filter....... .................. A................. ........... ........... ........... ........... ...........
A4483.............. Moisture exchanger........ .................. A................. ........... ........... ........... ........... ...........
A4490.............. Above knee surgical .................. E................. ........... ........... ........... ........... ...........
stocking.
A4495.............. Thigh length surg stocking .................. E................. ........... ........... ........... ........... ...........
A4500.............. Below knee surgical .................. E................. ........... ........... ........... ........... ...........
stocking.
A4510.............. Full length surg stocking. .................. E................. ........... ........... ........... ........... ...........
A4520.............. Incontinence garment .................. E................. ........... ........... ........... ........... ...........
anytype.
A4550.............. Surgical trays............ .................. B................. ........... ........... ........... ........... ...........
A4554.............. Disposable underpads...... .................. E................. ........... ........... ........... ........... ...........
A4556.............. Electrodes, pair.......... .................. Y................. ........... ........... ........... ........... ...........
A4557.............. Lead wires, pair.......... .................. Y................. ........... ........... ........... ........... ...........
A4558.............. Conductive gel or paste... .................. Y................. ........... ........... ........... ........... ...........
A4559.............. Coupling gel or paste..... .................. Y................. ........... ........... ........... ........... ...........
A4561.............. Pessary rubber, any type.. .................. N................. ........... ........... ........... ........... ...........
A4562.............. Pessary, non rubber,any .................. N................. ........... ........... ........... ........... ...........
type.
A4565.............. Slings.................... .................. A................. ........... ........... ........... ........... ...........
A4570.............. Splint.................... .................. E................. ........... ........... ........... ........... ...........
A4575.............. Hyperbaric o2 chamber .................. E................. ........... ........... ........... ........... ...........
disps.
A4580.............. Cast supplies (plaster)... .................. E................. ........... ........... ........... ........... ...........
A4590.............. Special casting material.. .................. E................. ........... ........... ........... ........... ...........
A4595.............. TENS suppl 2 lead per .................. Y................. ........... ........... ........... ........... ...........
month.
A4600.............. Sleeve, inter limb comp .................. Y................. ........... ........... ........... ........... ...........
dev.
A4601.............. Lith ion batt, non-pros .................. Y................. ........... ........... ........... ........... ...........
use.
A4604.............. Tubing with heating .................. Y................. ........... ........... ........... ........... ...........
element.
A4605.............. Trach suction cath close .................. Y................. ........... ........... ........... ........... ...........
sys.
A4606.............. Oxygen probe used w .................. A................. ........... ........... ........... ........... ...........
oximeter.
A4608.............. Transtracheal oxygen cath. .................. Y................. ........... ........... ........... ........... ...........
A4611.............. Heavy duty battery........ .................. Y................. ........... ........... ........... ........... ...........
A4612.............. Battery cables............ .................. Y................. ........... ........... ........... ........... ...........
A4613.............. Battery charger........... .................. Y................. ........... ........... ........... ........... ...........
A4614.............. Hand-held PEFR meter...... .................. N................. ........... ........... ........... ........... ...........
A4615.............. Cannula nasal............. .................. Y................. ........... ........... ........... ........... ...........
A4616.............. Tubing (oxygen) per foot.. .................. Y................. ........... ........... ........... ........... ...........
A4617.............. Mouth piece............... .................. Y................. ........... ........... ........... ........... ...........
A4618.............. Breathing circuits........ .................. Y................. ........... ........... ........... ........... ...........
A4619.............. Face tent................. .................. Y................. ........... ........... ........... ........... ...........
A4620.............. Variable concentration .................. Y................. ........... ........... ........... ........... ...........
mask.
A4623.............. Tracheostomy inner cannula .................. A................. ........... ........... ........... ........... ...........
A4624.............. Tracheal suction tube..... .................. Y................. ........... ........... ........... ........... ...........
A4625.............. Trach care kit for new .................. A................. ........... ........... ........... ........... ...........
trach.
A4626.............. Tracheostomy cleaning .................. A................. ........... ........... ........... ........... ...........
brush.
A4627.............. Spacer bag/reservoir...... .................. E................. ........... ........... ........... ........... ...........
A4628.............. Oropharyngeal suction cath .................. Y................. ........... ........... ........... ........... ...........
A4629.............. Tracheostomy care kit..... .................. A................. ........... ........... ........... ........... ...........
A4630.............. Repl bat t.e.n.s. own by .................. Y................. ........... ........... ........... ........... ...........
pt.
A4633.............. Uvl replacement bulb...... .................. Y................. ........... ........... ........... ........... ...........
[[Page 67111]]
A4634.............. Replacement bulb th .................. A................. ........... ........... ........... ........... ...........
lightbox.
A4635.............. Underarm crutch pad....... .................. Y................. ........... ........... ........... ........... ...........
A4636.............. Handgrip for cane etc..... .................. Y................. ........... ........... ........... ........... ...........
A4637.............. Repl tip cane/crutch/ .................. Y................. ........... ........... ........... ........... ...........
walker.
A4638.............. Repl batt pulse gen sys... .................. Y................. ........... ........... ........... ........... ...........
A4639.............. Infrared ht sys replcmnt .................. Y................. ........... ........... ........... ........... ...........
pad.
A4640.............. Alternating pressure pad.. .................. Y................. ........... ........... ........... ........... ...........
A4641.............. Radiopharm dx agent noc... .................. N................. ........... ........... ........... ........... ...........
A4642.............. In111 satumomab........... CH................ N................. ........... ........... ........... ........... ...........
A4648.............. Implantable tissue marker. NI................ N................. ........... ........... ........... ........... ...........
A4649.............. Surgical supplies......... .................. A................. ........... ........... ........... ........... ...........
A4650.............. Implant radiation NI................ N................. ........... ........... ........... ........... ...........
dosimeter.
A4651.............. Calibrated microcap tube.. .................. A................. ........... ........... ........... ........... ...........
A4652.............. Microcapillary tube .................. A................. ........... ........... ........... ........... ...........
sealant.
A4653.............. PD catheter anchor belt... .................. A................. ........... ........... ........... ........... ...........
A4657.............. Syringe w/wo needle....... .................. A................. ........... ........... ........... ........... ...........
A4660.............. Sphyg/bp app w cuff and .................. A................. ........... ........... ........... ........... ...........
stet.
A4663.............. Dialysis blood pressure .................. A................. ........... ........... ........... ........... ...........
cuff.
A4670.............. Automatic bp monitor, dial .................. E................. ........... ........... ........... ........... ...........
A4671.............. Disposable cycler set..... .................. B................. ........... ........... ........... ........... ...........
A4672.............. Drainage ext line, .................. B................. ........... ........... ........... ........... ...........
dialysis.
A4673.............. Ext line w easy lock .................. B................. ........... ........... ........... ........... ...........
connect.
A4674.............. Chem/antisept solution, .................. B................. ........... ........... ........... ........... ...........
8oz.
A4680.............. Activated carbon filter, .................. A................. ........... ........... ........... ........... ...........
ea.
A4690.............. Dialyzer, each............ .................. A................. ........... ........... ........... ........... ...........
A4706.............. Bicarbonate conc sol per .................. A................. ........... ........... ........... ........... ...........
gal.
A4707.............. Bicarbonate conc pow per .................. A................. ........... ........... ........... ........... ...........
pac.
A4708.............. Acetate conc sol per .................. A................. ........... ........... ........... ........... ...........
gallon.
A4709.............. Acid conc sol per gallon.. .................. A................. ........... ........... ........... ........... ...........
A4714.............. Treated water per gallon.. .................. A................. ........... ........... ........... ........... ...........
A4719.............. Y set tubing.
A4720.............. Dialysat sol fld vol > .................. A................. ........... ........... ........... ........... ...........
249cc.
A4721.............. Dialysat sol fld vol > .................. A................. ........... ........... ........... ........... ...........
999cc.
A4722.............. Dialys sol fld vol > .................. A................. ........... ........... ........... ........... ...........
1999cc.
A4723.............. Dialys sol fld vol > .................. A................. ........... ........... ........... ........... ...........
2999cc.
A4724.............. Dialys sol fld vol > .................. A................. ........... ........... ........... ........... ...........
3999cc.
A4725.............. Dialys sol fld vol > .................. A................. ........... ........... ........... ........... ...........
4999cc.
A4726.............. Dialys sol fld vol > .................. A................. ........... ........... ........... ........... ...........
5999cc.
A4728.............. Dialysate solution, non- .................. B................. ........... ........... ........... ........... ...........
dex.
A4730.............. Fistula cannulation set, .................. A................. ........... ........... ........... ........... ...........
ea.
A4736.............. Topical anesthetic, per .................. A................. ........... ........... ........... ........... ...........
gram.
A4737.............. Inj anesthetic per 10 ml.. .................. A................. ........... ........... ........... ........... ...........
A4740.............. Shunt accessory........... .................. A................. ........... ........... ........... ........... ...........
A4750.............. Art or venous blood tubing .................. A................. ........... ........... ........... ........... ...........
A4755.............. Comb art/venous blood .................. A................. ........... ........... ........... ........... ...........
tubing.
A4760.............. Dialysate sol test kit, .................. A................. ........... ........... ........... ........... ...........
each.
A4765.............. Dialysate conc pow per .................. A................. ........... ........... ........... ........... ...........
pack.
A4766.............. Dialysate conc sol add 10 .................. A................. ........... ........... ........... ........... ...........
ml.
A4770.............. Blood collection tube/ .................. A................. ........... ........... ........... ........... ...........
vacuum.
A4771.............. Serum clotting time tube.. .................. A................. ........... ........... ........... ........... ...........
A4772.............. Blood glucose test strips. .................. A................. ........... ........... ........... ........... ...........
A4773.............. Occult blood test strips.. .................. A................. ........... ........... ........... ........... ...........
A4774.............. Ammonia test strips....... .................. A................. ........... ........... ........... ........... ...........
A4802.............. Protamine sulfate per 50 .................. A................. ........... ........... ........... ........... ...........
mg.
A4860.............. Disposable catheter tips.. .................. A................. ........... ........... ........... ........... ...........
A4870.............. Plumb/elec wk hm hemo .................. A................. ........... ........... ........... ........... ...........
equip.
A4890.............. Repair/maint cont hemo .................. A................. ........... ........... ........... ........... ...........
equip.
A4911.............. Drain bag/bottle.......... .................. A................. ........... ........... ........... ........... ...........
A4913.............. Misc dialysis supplies noc .................. A................. ........... ........... ........... ........... ...........
A4918.............. Venous pressure clamp..... .................. A................. ........... ........... ........... ........... ...........
A4927.............. Non-sterile gloves........ .................. A................. ........... ........... ........... ........... ...........
A4928.............. Surgical mask............. .................. A................. ........... ........... ........... ........... ...........
A4929.............. Tourniquet for dialysis, .................. A................. ........... ........... ........... ........... ...........
ea.
A4930.............. Sterile, gloves per pair.. .................. A................. ........... ........... ........... ........... ...........
A4931.............. Reusable oral thermometer. .................. A................. ........... ........... ........... ........... ...........
A4932.............. Reusable rectal .................. E................. ........... ........... ........... ........... ...........
thermometer.
A5051.............. Pouch clsd w barr attached .................. A................. ........... ........... ........... ........... ...........
A5052.............. Clsd ostomy pouch w/o barr .................. A................. ........... ........... ........... ........... ...........
A5053.............. Clsd ostomy pouch .................. A................. ........... ........... ........... ........... ...........
faceplate.
A5054.............. Clsd ostomy pouch w/flange .................. A................. ........... ........... ........... ........... ...........
A5055.............. Stoma cap................. .................. A................. ........... ........... ........... ........... ...........
A5061.............. Pouch drainable w barrier .................. A................. ........... ........... ........... ........... ...........
at.
A5062.............. Drnble ostomy pouch w/o .................. A................. ........... ........... ........... ........... ...........
barr.
A5063.............. Drain ostomy pouch w/ .................. A................. ........... ........... ........... ........... ...........
flange.
A5071.............. Urinary pouch w/barrier... .................. A................. ........... ........... ........... ........... ...........
A5072.............. Urinary pouch w/o barrier. .................. A................. ........... ........... ........... ........... ...........
A5073.............. Urinary pouch on barr w/ .................. A................. ........... ........... ........... ........... ...........
flng.
A5081.............. Continent stoma plug...... .................. A................. ........... ........... ........... ........... ...........
A5082.............. Continent stoma catheter.. .................. A................. ........... ........... ........... ........... ...........
A5083.............. Stoma absorptive cover.... NI................ A................. ........... ........... ........... ........... ...........
[[Page 67112]]
A5093.............. Ostomy accessory convex .................. A................. ........... ........... ........... ........... ...........
inse.
A5102.............. Bedside drain btl w/wo .................. A................. ........... ........... ........... ........... ...........
tube.
A5105.............. Urinary suspensory........ .................. A................. ........... ........... ........... ........... ...........
A5112.............. Urinary leg bag........... .................. A................. ........... ........... ........... ........... ...........
A5113.............. Latex leg strap........... .................. A................. ........... ........... ........... ........... ...........
A5114.............. Foam/fabric leg strap..... .................. A................. ........... ........... ........... ........... ...........
A5120.............. Skin barrier, wipe or swab .................. A................. ........... ........... ........... ........... ...........
A5121.............. Solid skin barrier 6x6.... .................. A................. ........... ........... ........... ........... ...........
A5122.............. Solid skin barrier 8x8.... .................. A................. ........... ........... ........... ........... ...........
A5126.............. Disk/foam pad +or- .................. A................. ........... ........... ........... ........... ...........
adhesive.
A5131.............. Appliance cleaner......... .................. A................. ........... ........... ........... ........... ...........
A5200.............. Percutaneous catheter .................. A................. ........... ........... ........... ........... ...........
anchor.
A5500.............. Diab shoe for density .................. Y................. ........... ........... ........... ........... ...........
insert.
A5501.............. Diabetic custom molded .................. Y................. ........... ........... ........... ........... ...........
shoe.
A5503.............. Diabetic shoe w/roller/ .................. Y................. ........... ........... ........... ........... ...........
rockr.
A5504.............. Diabetic shoe with wedge.. .................. Y................. ........... ........... ........... ........... ...........
A5505.............. Diab shoe w/metatarsal bar .................. Y................. ........... ........... ........... ........... ...........
A5506.............. Diabetic shoe w/off set .................. Y................. ........... ........... ........... ........... ...........
heel.
A5507.............. Modification diabetic shoe .................. Y................. ........... ........... ........... ........... ...........
A5508.............. Diabetic deluxe shoe...... .................. Y................. ........... ........... ........... ........... ...........
A5510.............. Compression form shoe .................. E................. ........... ........... ........... ........... ...........
insert.
A5512.............. Multi den insert direct .................. Y................. ........... ........... ........... ........... ...........
form.
A5513.............. Multi den insert custom .................. Y................. ........... ........... ........... ........... ...........
mold.
A6000.............. Wound warming wound cover. .................. E................. ........... ........... ........... ........... ...........
A6010.............. Collagen based wound .................. A................. ........... ........... ........... ........... ...........
filler.
A6011.............. Collagen gel/paste wound .................. A................. ........... ........... ........... ........... ...........
fil.
A6021.............. Collagen dressing <=16 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6022.............. Collagen drsg>6<=48 sq in. .................. A................. ........... ........... ........... ........... ...........
A6023.............. Collagen dressing >48 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6024.............. Collagen dsg wound filler. .................. A................. ........... ........... ........... ........... ...........
A6025.............. Silicone gel sheet, each.. .................. E................. ........... ........... ........... ........... ...........
A6154.............. Wound pouch each.......... .................. A................. ........... ........... ........... ........... ...........
A6196.............. Alginate dressing <=16 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6197.............. Alginate drsg >16 <=48 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6198.............. alginate dressing > 48 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6199.............. Alginate drsg wound filler .................. A................. ........... ........... ........... ........... ...........
A6200.............. Compos drsg <=16 no border .................. E................. ........... ........... ........... ........... ...........
A6201.............. Compos drsg >16<=48 no bdr .................. E................. ........... ........... ........... ........... ...........
A6202.............. Compos drsg >48 no border. .................. E................. ........... ........... ........... ........... ...........
A6203.............. Composite drsg <= 16 sq in .................. A................. ........... ........... ........... ........... ...........
A6204.............. Composite drsg >16<=48 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6205.............. Composite drsg > 48 sq in. .................. A................. ........... ........... ........... ........... ...........
A6206.............. Contact layer <= 16 sq in. .................. A................. ........... ........... ........... ........... ...........
A6207.............. Contact layer >16<= 48 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6208.............. Contact layer > 48 sq in.. .................. A................. ........... ........... ........... ........... ...........
A6209.............. Foam drsg <=16 sq in w/o .................. A................. ........... ........... ........... ........... ...........
bdr.
A6210.............. Foam drg >16<=48 sq in w/o .................. A................. ........... ........... ........... ........... ...........
b.
A6211.............. Foam drg > 48 sq in w/o .................. A................. ........... ........... ........... ........... ...........
brdr.
A6212.............. Foam drg <=16 sq in w/ .................. A................. ........... ........... ........... ........... ...........
border.
A6213.............. Foam drg >16<=48 sq in w/ .................. A................. ........... ........... ........... ........... ...........
bdr.
A6214.............. Foam drg > 48 sq in w/ .................. A................. ........... ........... ........... ........... ...........
border.
A6215.............. Foam dressing wound filler .................. A................. ........... ........... ........... ........... ...........
A6216.............. Non-sterile gauze<=16 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6217.............. Non-sterile gauze>16<=48 .................. A................. ........... ........... ........... ........... ...........
sq.
A6218.............. Non-sterile gauze > 48 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6219.............. Gauze <= 16 sq in w/border .................. A................. ........... ........... ........... ........... ...........
A6220.............. Gauze >16 <=48 sq in w/ .................. A................. ........... ........... ........... ........... ...........
bordr.
A6221.............. Gauze > 48 sq in w/border. .................. A................. ........... ........... ........... ........... ...........
A6222.............. Gauze <=16 in no w/sal w/o .................. A................. ........... ........... ........... ........... ...........
b.
A6223.............. Gauze >16<=48 no w/sal w/o .................. A................. ........... ........... ........... ........... ...........
b.
A6224.............. Gauze > 48 in no w/sal w/o .................. A................. ........... ........... ........... ........... ...........
b.
A6228.............. Gauze <= 16 sq in water/ .................. A................. ........... ........... ........... ........... ...........
sal.
A6229.............. Gauze >16<=48 sq in watr/ .................. A................. ........... ........... ........... ........... ...........
sal.
A6230.............. Gauze > 48 sq in water/ .................. A................. ........... ........... ........... ........... ...........
salne.
A6231.............. Hydrogel dsg<=16 sq in.... .................. A................. ........... ........... ........... ........... ...........
A6232.............. Hydrogel dsg>16<=48 sq in. .................. A................. ........... ........... ........... ........... ...........
A6233.............. Hydrogel dressing >48 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6234.............. Hydrocolld drg <=16 w/o .................. A................. ........... ........... ........... ........... ...........
bdr.
A6235.............. Hydrocolld drg >16<=48 w/o .................. A................. ........... ........... ........... ........... ...........
b.
A6236.............. Hydrocolld drg > 48 in w/o .................. A................. ........... ........... ........... ........... ...........
b.
A6237.............. Hydrocolld drg <=16 in w/ .................. A................. ........... ........... ........... ........... ...........
bdr.
A6238.............. Hydrocolld drg >16<=48 w/ .................. A................. ........... ........... ........... ........... ...........
bdr.
A6239.............. Hydrocolld drg > 48 in w/ .................. A................. ........... ........... ........... ........... ...........
bdr.
A6240.............. Hydrocolld drg filler .................. A................. ........... ........... ........... ........... ...........
paste.
A6241.............. Hydrocolloid drg filler .................. A................. ........... ........... ........... ........... ...........
dry.
A6242.............. Hydrogel drg <=16 in w/o .................. A................. ........... ........... ........... ........... ...........
bdr.
A6243.............. Hydrogel drg >16<=48 w/o .................. A................. ........... ........... ........... ........... ...........
bdr.
A6244.............. Hydrogel drg >48 in w/o .................. A................. ........... ........... ........... ........... ...........
bdr.
A6245.............. Hydrogel drg <= 16 in w/ .................. A................. ........... ........... ........... ........... ...........
bdr.
A6246.............. Hydrogel drg >16<=48 in w/ .................. A................. ........... ........... ........... ........... ...........
b.
[[Page 67113]]
A6247.............. Hydrogel drg > 48 sq in w/ .................. A................. ........... ........... ........... ........... ...........
b.
A6248.............. Hydrogel drsg gel filler.. .................. A................. ........... ........... ........... ........... ...........
A6250.............. Skin seal protect .................. A................. ........... ........... ........... ........... ...........
moisturizr.
A6251.............. Absorpt drg <=16 sq in w/o .................. A................. ........... ........... ........... ........... ...........
b.
A6252.............. Absorpt drg >16 <=48 w/o .................. A................. ........... ........... ........... ........... ...........
bdr.
A6253.............. Absorpt drg > 48 sq in w/o .................. A................. ........... ........... ........... ........... ...........
b.
A6254.............. Absorpt drg <=16 sq in w/ .................. A................. ........... ........... ........... ........... ...........
bdr.
A6255.............. Absorpt drg >16<=48 in w/ .................. A................. ........... ........... ........... ........... ...........
bdr.
A6256.............. Absorpt drg > 48 sq in w/ .................. A................. ........... ........... ........... ........... ...........
bdr.
A6257.............. Transparent film <= 16 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6258.............. Transparent film >16<=48 .................. A................. ........... ........... ........... ........... ...........
in.
A6259.............. Transparent film > 48 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6260.............. Wound cleanser any type/ .................. A................. ........... ........... ........... ........... ...........
size.
A6261.............. Wound filler gel/paste /oz .................. A................. ........... ........... ........... ........... ...........
A6262.............. Wound filler dry form / .................. A................. ........... ........... ........... ........... ...........
gram.
A6266.............. Impreg gauze no h20/sal/ .................. A................. ........... ........... ........... ........... ...........
yard.
A6402.............. Sterile gauze <= 16 sq in. .................. A................. ........... ........... ........... ........... ...........
A6403.............. Sterile gauze>16 <= 48 sq .................. A................. ........... ........... ........... ........... ...........
in.
A6404.............. Sterile gauze > 48 sq in.. .................. A................. ........... ........... ........... ........... ...........
A6407.............. Packing strips, non-impreg .................. A................. ........... ........... ........... ........... ...........
A6410.............. Sterile eye pad........... .................. A................. ........... ........... ........... ........... ...........
A6411.............. Non-sterile eye pad....... .................. A................. ........... ........... ........... ........... ...........
A6412.............. Occlusive eye patch....... .................. E................. ........... ........... ........... ........... ...........
A6413.............. Adhesive bandage, first- NI................ E................. ........... ........... ........... ........... ...........
aid.
A6441.............. Pad band w>=3/ <5//yd..... .................. A................. ........... ........... ........... ........... ...........
A6442.............. Conform band n/s w<3//yd.. .................. A................. ........... ........... ........... ........... ...........
A6443.............. Conform band n/s w>=3/<5// .................. A................. ........... ........... ........... ........... ...........
yd.
A6444.............. Conform band n/s w>=5//yd. .................. A................. ........... ........... ........... ........... ...........
A6445.............. Conform band s w <3//yd... .................. A................. ........... ........... ........... ........... ...........
A6446.............. Conform band s w>=3/ <5// .................. A................. ........... ........... ........... ........... ...........
yd.
A6447.............. Conform band s w >=5//yd.. .................. A................. ........... ........... ........... ........... ...........
A6448.............. Lt compres band <3//yd.... .................. A................. ........... ........... ........... ........... ...........
A6449.............. Lt compres band >=3/ =5//yd... .................. A................. ........... ........... ........... ........... ...........
A6451.............. Mod compres band w>=3/<5// .................. A................. ........... ........... ........... ........... ...........
yd.
A6452.............. High compres band w>=3/<5/ .................. A................. ........... ........... ........... ........... ...........
yd.
A6453.............. Self-adher band w <3//yd.. .................. A................. ........... ........... ........... ........... ...........
A6454.............. Self-adher band w>=3/ <5// .................. A................. ........... ........... ........... ........... ...........
yd.
A6455.............. Self-adher band >=5//yd... .................. A................. ........... ........... ........... ........... ...........
A6456.............. Zinc paste band w >=3/<5// .................. A................. ........... ........... ........... ........... ...........
yd.
A6457.............. Tubular dressing.......... .................. A................. ........... ........... ........... ........... ...........
A6501.............. Compres burngarment .................. A................. ........... ........... ........... ........... ...........
bodysuit.
A6502.............. Compres burngarment .................. A................. ........... ........... ........... ........... ...........
chinstrp.
A6503.............. Compres burngarment .................. A................. ........... ........... ........... ........... ...........
facehood.
A6504.............. Cmprsburngarment glove- .................. A................. ........... ........... ........... ........... ...........
wrist.
A6505.............. Cmprsburngarment glove- .................. A................. ........... ........... ........... ........... ...........
elbow.
A6506.............. Cmprsburngrmnt glove- .................. A................. ........... ........... ........... ........... ...........
axilla.
A6507.............. Cmprs burngarment foot- .................. A................. ........... ........... ........... ........... ...........
knee.
A6508.............. Cmprs burngarment foot- .................. A................. ........... ........... ........... ........... ...........
thigh.
A6509.............. Compres burn garment .................. A................. ........... ........... ........... ........... ...........
jacket.
A6510.............. Compres burn garment .................. A................. ........... ........... ........... ........... ...........
leotard.
A6511.............. Compres burn garment panty .................. A................. ........... ........... ........... ........... ...........
A6512.............. Compres burn garment, noc. .................. A................. ........... ........... ........... ........... ...........
A6513.............. Compress burn mask face/ .................. B................. ........... ........... ........... ........... ...........
neck.
A6530.............. Compression stocking BK18- .................. E................. ........... ........... ........... ........... ...........
30.
A6531.............. Compression stocking BK30- .................. A................. ........... ........... ........... ........... ...........
40.
A6532.............. Compression stocking BK40- .................. A................. ........... ........... ........... ........... ...........
50.
A6533.............. Gc stocking thighlngth 18- .................. E................. ........... ........... ........... ........... ...........
30.
A6534.............. Gc stocking thighlngth 30- .................. E................. ........... ........... ........... ........... ...........
40.
A6535.............. Gc stocking thighlngth 40- .................. E................. ........... ........... ........... ........... ...........
50.
A6536.............. Gc stocking full lngth 18- .................. E................. ........... ........... ........... ........... ...........
30.
A6537.............. Gc stocking full lngth 30- .................. E................. ........... ........... ........... ........... ...........
40.
A6538.............. Gc stocking full lngth 40- .................. E................. ........... ........... ........... ........... ...........
50.
A6539.............. Gc stocking waistlngth 18- .................. E................. ........... ........... ........... ........... ...........
30.
A6540.............. Gc stocking waistlngth 30- .................. E................. ........... ........... ........... ........... ...........
40.
A6541.............. Gc stocking waistlngth 40- .................. E................. ........... ........... ........... ........... ...........
50.
A6542.............. Gc stocking custom made... .................. E................. ........... ........... ........... ........... ...........
A6543.............. Gc stocking lymphedema.... .................. E................. ........... ........... ........... ........... ...........
A6544.............. Gc stocking garter belt... .................. E................. ........... ........... ........... ........... ...........
A6549.............. G compression stocking.... .................. E................. ........... ........... ........... ........... ...........
A6550.............. Neg pres wound ther drsg .................. Y................. ........... ........... ........... ........... ...........
set.
A7000.............. Disposable canister for .................. Y................. ........... ........... ........... ........... ...........
pump.
A7001.............. Nondisposable pump .................. Y................. ........... ........... ........... ........... ...........
canister.
A7002.............. Tubing used w suction pump .................. Y................. ........... ........... ........... ........... ...........
A7003.............. Nebulizer administration .................. Y................. ........... ........... ........... ........... ...........
set.
A7004.............. Disposable nebulizer sml .................. Y................. ........... ........... ........... ........... ...........
vol.
A7005.............. Nondisposable nebulizer .................. Y................. ........... ........... ........... ........... ...........
set.
A7006.............. Filtered nebulizer admin .................. Y................. ........... ........... ........... ........... ...........
set.
A7007.............. Lg vol nebulizer .................. Y................. ........... ........... ........... ........... ...........
disposable.
A7008.............. Disposable nebulizer .................. Y................. ........... ........... ........... ........... ...........
prefill.
[[Page 67114]]
A7009.............. Nebulizer reservoir bottle .................. Y................. ........... ........... ........... ........... ...........
A7010.............. Disposable corrugated .................. Y................. ........... ........... ........... ........... ...........
tubing.
A7011.............. Nondispos corrugated .................. Y................. ........... ........... ........... ........... ...........
tubing.
A7012.............. Nebulizer water collec .................. Y................. ........... ........... ........... ........... ...........
devic.
A7013.............. Disposable compressor .................. Y................. ........... ........... ........... ........... ...........
filter.
A7014.............. Compressor nondispos .................. Y................. ........... ........... ........... ........... ...........
filter.
A7015.............. Aerosol mask used w .................. Y................. ........... ........... ........... ........... ...........
nebulize.
A7016.............. Nebulizer dome & .................. Y................. ........... ........... ........... ........... ...........
mouthpiece.
A7017.............. Nebulizer not used w .................. Y................. ........... ........... ........... ........... ...........
oxygen.
A7018.............. Water distilled w/ .................. Y................. ........... ........... ........... ........... ...........
nebulizer.
A7025.............. Replace chest compress .................. Y................. ........... ........... ........... ........... ...........
vest.
A7026.............. Replace chst cmprss sys .................. Y................. ........... ........... ........... ........... ...........
hose.
A7027.............. Combination oral/nasal NI................ Y................. ........... ........... ........... ........... ...........
mask.
A7028.............. Repl oral cushion combo NI................ Y................. ........... ........... ........... ........... ...........
mask.
A7029.............. Repl nasal pillow comb NI................ Y................. ........... ........... ........... ........... ...........
mask.
A7030.............. CPAP full face mask....... .................. Y................. ........... ........... ........... ........... ...........
A7031.............. Replacement facemask .................. Y................. ........... ........... ........... ........... ...........
interfa.
A7032.............. Replacement nasal cushion. .................. Y................. ........... ........... ........... ........... ...........
A7033.............. Replacement nasal pillows. .................. Y................. ........... ........... ........... ........... ...........
A7034.............. Nasal application device.. .................. Y................. ........... ........... ........... ........... ...........
A7035.............. Pos airway press headgear. .................. Y................. ........... ........... ........... ........... ...........
A7036.............. Pos airway press chinstrap .................. Y................. ........... ........... ........... ........... ...........
A7037.............. Pos airway pressure tubing .................. Y................. ........... ........... ........... ........... ...........
A7038.............. Pos airway pressure filter .................. Y................. ........... ........... ........... ........... ...........
A7039.............. Filter, non disposable w .................. Y................. ........... ........... ........... ........... ...........
pap.
A7040.............. One way chest drain valve. .................. A................. ........... ........... ........... ........... ...........
A7041.............. Water seal drain container .................. A................. ........... ........... ........... ........... ...........
A7042.............. Implanted pleural catheter .................. A................. ........... ........... ........... ........... ...........
A7043.............. Vacuum drainagebottle/ .................. A................. ........... ........... ........... ........... ...........
tubing.
A7044.............. PAP oral interface........ .................. Y................. ........... ........... ........... ........... ...........
A7045.............. Repl exhalation port for .................. Y................. ........... ........... ........... ........... ...........
PAP.
A7046.............. Repl water chamber, PAP .................. Y................. ........... ........... ........... ........... ...........
dev.
A7501.............. Tracheostoma valve w .................. A................. ........... ........... ........... ........... ...........
diaphra.
A7502.............. Replacement diaphragm/ .................. A................. ........... ........... ........... ........... ...........
fplate.
A7503.............. HMES filter holder or cap. .................. A................. ........... ........... ........... ........... ...........
A7504.............. Tracheostoma HMES filter.. .................. A................. ........... ........... ........... ........... ...........
A7505.............. HMES or trach valve .................. A................. ........... ........... ........... ........... ...........
housing.
A7506.............. HMES/trachvalve .................. A................. ........... ........... ........... ........... ...........
adhesivedisk.
A7507.............. Integrated filter & holder .................. A................. ........... ........... ........... ........... ...........
A7508.............. Housing & Integrated .................. A................. ........... ........... ........... ........... ...........
Adhesiv.
A7509.............. Heat & moisture exchange .................. A................. ........... ........... ........... ........... ...........
sys.
A7520.............. Trach/laryn tube non- .................. A................. ........... ........... ........... ........... ...........
cuffed.
A7521.............. Trach/laryn tube cuffed... .................. A................. ........... ........... ........... ........... ...........
A7522.............. Trach/laryn tube stainless .................. A................. ........... ........... ........... ........... ...........
A7523.............. Tracheostomy shower .................. A................. ........... ........... ........... ........... ...........
protect.
A7524.............. Tracheostoma stent/stud/ .................. A................. ........... ........... ........... ........... ...........
bttn.
A7525.............. Tracheostomy mask......... .................. A................. ........... ........... ........... ........... ...........
A7526.............. Tracheostomy tube collar.. .................. A................. ........... ........... ........... ........... ...........
A7527.............. Trach/laryn tube plug/stop .................. A................. ........... ........... ........... ........... ...........
A8000.............. Soft protect helmet prefab .................. Y................. ........... ........... ........... ........... ...........
A8001.............. Hard protect helmet prefab .................. Y................. ........... ........... ........... ........... ...........
A8002.............. Soft protect helmet custom .................. Y................. ........... ........... ........... ........... ...........
A8003.............. Hard protect helmet custom .................. Y................. ........... ........... ........... ........... ...........
A8004.............. Repl soft interface, .................. Y................. ........... ........... ........... ........... ...........
helmet.
A9150.............. Misc/exper non-prescript .................. B................. ........... ........... ........... ........... ...........
dru.
A9152.............. Single vitamin nos........ .................. E................. ........... ........... ........... ........... ...........
A9153.............. Multi-vitamin nos......... .................. E................. ........... ........... ........... ........... ...........
A9155.............. Artificial saliva......... NI................ B................. ........... ........... ........... ........... ...........
A9180.............. Lice treatment, topical... .................. E................. ........... ........... ........... ........... ...........
A9270.............. Non-covered item or .................. E................. ........... ........... ........... ........... ...........
service.
A9274.............. Ext amb insulin delivery NI................ E................. ........... ........... ........... ........... ...........
sys.
A9275.............. Disp home glucose monitor. .................. E................. ........... ........... ........... ........... ...........
A9276.............. Disposable sensor, CGM sys NI................ E................. ........... ........... ........... ........... ...........
A9277.............. External transmitter, CGM. NI................ E................. ........... ........... ........... ........... ...........
A9278.............. External receiver, CGM sys NI................ E................. ........... ........... ........... ........... ...........
A9279.............. Monitoring feature/ .................. E................. ........... ........... ........... ........... ...........
deviceNOC.
A9280.............. Alert device, noc......... .................. E................. ........... ........... ........... ........... ...........
A9281.............. Reaching/grabbing device.. .................. E................. ........... ........... ........... ........... ...........
A9282.............. Wig any type.............. .................. E................. ........... ........... ........... ........... ...........
A9283.............. Foot press off load supp NI................ E................. ........... ........... ........... ........... ...........
dev.
A9300.............. Exercise equipment........ .................. E................. ........... ........... ........... ........... ...........
A9500.............. Tc99m sestamibi........... CH................ N................. ........... ........... ........... ........... ...........
A9501.............. Technetium TC-99m NI................ N................. ........... ........... ........... ........... ...........
teboroxime.
A9502.............. Tc99m tetrofosmin......... CH................ N................. ........... ........... ........... ........... ...........
A9503.............. Tc99m medronate........... .................. N................. ........... ........... ........... ........... ...........
A9504.............. Tc99m apcitide............ .................. N................. ........... ........... ........... ........... ...........
A9505.............. TL201 thallium............ CH................ N................. ........... ........... ........... ........... ...........
A9507.............. In111 capromab............ CH................ N................. ........... ........... ........... ........... ...........
A9508.............. I131 iodobenguate, dx..... CH................ N................. ........... ........... ........... ........... ...........
A9509.............. Iodine I-123 sod iodide NI................ N................. ........... ........... ........... ........... ...........
mil.
[[Page 67115]]
A9510.............. Tc99m disofenin........... .................. N................. ........... ........... ........... ........... ...........
A9512.............. Tc99m pertechnetate....... .................. N................. ........... ........... ........... ........... ...........
A9516.............. Iodine I-123 sod iodide CH................ N................. ........... ........... ........... ........... ...........
mic.
A9517.............. I131 iodide cap, rx....... CH................ K................. 1064 0.2393 $15.24 ........... $3.05
A9521.............. Tc99m exametazime......... CH................ N................. ........... ........... ........... ........... ...........
A9524.............. I131 serum albumin, dx.... CH................ N................. ........... ........... ........... ........... ...........
A9526.............. Nitrogen N-13 ammonia..... CH................ N................. ........... ........... ........... ........... ...........
A9527.............. Iodine I-125 sodium iodide CH................ K................. 2632 0.4325 $27.55 ........... $5.51
A9528.............. Iodine I-131 iodide cap, CH................ N................. ........... ........... ........... ........... ...........
dx.
A9529.............. I131 iodide sol, dx....... .................. N................. ........... ........... ........... ........... ...........
A9530.............. I131 iodide sol, rx....... CH................ K................. 1150 0.1762 $11.22 ........... $2.24
A9531.............. I131 max 100uCi........... .................. N................. ........... ........... ........... ........... ...........
A9532.............. I125 serum albumin, dx.... .................. N................. ........... ........... ........... ........... ...........
A9535.............. Injection, methylene blue. .................. N................. ........... ........... ........... ........... ...........
A9536.............. Tc99m depreotide.......... CH................ N................. ........... ........... ........... ........... ...........
A9537.............. Tc99m mebrofenin.......... .................. N................. ........... ........... ........... ........... ...........
A9538.............. Tc99m pyrophosphate....... .................. N................. ........... ........... ........... ........... ...........
A9539.............. Tc99m pentetate........... CH................ N................. ........... ........... ........... ........... ...........
A9540.............. Tc99m MAA................. .................. N................. ........... ........... ........... ........... ...........
A9541.............. Tc99m sulfur colloid...... .................. N................. ........... ........... ........... ........... ...........
A9542.............. In111 ibritumomab, dx..... CH................ N................. ........... ........... ........... ........... ...........
A9543.............. Y90 ibritumomab, rx....... CH................ K................. 1643 235.8764 $15,023.91 ........... $3,004.78
A9544.............. I131 tositumomab, dx...... CH................ N................. ........... ........... ........... ........... ...........
A9545.............. I131 tositumomab, rx...... CH................ K................. 1645 176.8495 $11,264.25 ........... $2,252.85
A9546.............. Co57/58................... CH................ N................. ........... ........... ........... ........... ...........
A9547.............. In111 oxyquinoline........ CH................ N................. ........... ........... ........... ........... ...........
A9548.............. In111 pentetate........... CH................ N................. ........... ........... ........... ........... ...........
A9550.............. Tc99m gluceptate.......... CH................ N................. ........... ........... ........... ........... ...........
A9551.............. Tc99m succimer............ CH................ N................. ........... ........... ........... ........... ...........
A9552.............. F18 fdg................... CH................ N................. ........... ........... ........... ........... ...........
A9553.............. Cr51 chromate............. CH................ N................. ........... ........... ........... ........... ...........
A9554.............. I125 iothalamate, dx...... .................. N................. ........... ........... ........... ........... ...........
A9555.............. Rb82 rubidium............. CH................ N................. ........... ........... ........... ........... ...........
A9556.............. Ga67 gallium.............. CH................ N................. ........... ........... ........... ........... ...........
A9557.............. Tc99m bicisate............ CH................ N................. ........... ........... ........... ........... ...........
A9558.............. Xe133 xenon 10mci......... .................. N................. ........... ........... ........... ........... ...........
A9559.............. Co57 cyano................ CH................ N................. ........... ........... ........... ........... ...........
A9560.............. Tc99m labeled rbc......... CH................ N................. ........... ........... ........... ........... ...........
A9561.............. Tc99m oxidronate.......... .................. N................. ........... ........... ........... ........... ...........
A9562.............. Tc99m mertiatide.......... CH................ N................. ........... ........... ........... ........... ...........
A9563.............. P32 Na phosphate.......... CH................ K................. 1675 1.7835 $113.60 ........... $22.72
A9564.............. P32 chromic phosphate..... CH................ K................. 1676 1.8711 $119.18 ........... $23.84
A9565.............. In111 pentetreotide....... CH................ D................. ........... ........... ........... ........... ...........
A9566.............. Tc99m fanolesomab......... CH................ N................. ........... ........... ........... ........... ...........
A9567.............. Technetium TC-99m aerosol. CH................ N................. ........... ........... ........... ........... ...........
A9568.............. Technetium tc99m CH................ N................. ........... ........... ........... ........... ...........
arcitumomab.
A9569.............. Technetium TC-99m auto WBC NI................ N................. ........... ........... ........... ........... ...........
A9570.............. Indium In-111 auto WBC.... NI................ N................. ........... ........... ........... ........... ...........
A9571.............. Indium IN-111 auto NI................ N................. ........... ........... ........... ........... ...........
platelet.
A9572.............. Indium In-111 NI................ N................. ........... ........... ........... ........... ...........
pentetreotide.
A9576.............. Inj prohance multipack.... NI................ N................. ........... ........... ........... ........... ...........
A9577.............. Inj multihance............ NI................ N................. ........... ........... ........... ........... ...........
A9578.............. Inj multihance multipack.. NI................ N................. ........... ........... ........... ........... ...........
A9579.............. Gad-base MR contrast NI................ N................. ........... ........... ........... ........... ...........
NOS,1ml.
A9600.............. Sr89 strontium............ CH................ K................. 0701 9.6094 $612.06 ........... $122.41
A9605.............. Sm 153 lexidronm.......... CH................ K................. 0702 21.3689 $1,361.07 ........... $272.21
A9698.............. Non-rad contrast .................. N................. ........... ........... ........... ........... ...........
materialNOC.
A9699.............. Radiopharm rx agent noc... .................. N................. ........... ........... ........... ........... ...........
A9700.............. Echocardiography Contrast. .................. B................. ........... ........... ........... ........... ...........
A9900.............. Supply/accessory/service.. .................. Y................. ........... ........... ........... ........... ...........
A9901.............. Delivery/set up/dispensing .................. A................. ........... ........... ........... ........... ...........
A9999.............. DME supply or accessory, .................. Y................. ........... ........... ........... ........... ...........
nos.
B4034.............. Enter feed supkit syr by .................. Y................. ........... ........... ........... ........... ...........
day.
B4035.............. Enteral feed supp pump per .................. Y................. ........... ........... ........... ........... ...........
d.
B4036.............. Enteral feed sup kit grav .................. Y................. ........... ........... ........... ........... ...........
by.
B4081.............. Enteral ng tubing w/ .................. Y................. ........... ........... ........... ........... ...........
stylet.
B4082.............. Enteral ng tubing w/o .................. Y................. ........... ........... ........... ........... ...........
stylet.
B4083.............. Enteral stomach tube .................. Y................. ........... ........... ........... ........... ...........
levine.
B4086.............. Gastrostomy/jejunostomy CH................ D................. ........... ........... ........... ........... ...........
tube.
B4087.............. Gastro/jejuno tube, std... NI................ A................. ........... ........... ........... ........... ...........
B4088.............. Gastro/jejuno tube, low- NI................ A................. ........... ........... ........... ........... ...........
pro.
B4100.............. Food thickener oral....... .................. E................. ........... ........... ........... ........... ...........
B4102.............. EF adult fluids and .................. Y................. ........... ........... ........... ........... ...........
electro.
B4103.............. EF ped fluid and .................. Y................. ........... ........... ........... ........... ...........
electrolyte.
B4104.............. Additive for enteral .................. E................. ........... ........... ........... ........... ...........
formula.
B4149.............. EF blenderized foods...... .................. Y................. ........... ........... ........... ........... ...........
B4150.............. EF complet w/intact .................. Y................. ........... ........... ........... ........... ...........
nutrient.
B4152.............. EF calorie dense>/=1.5Kcal .................. Y................. ........... ........... ........... ........... ...........
B4153.............. EF hydrolyzed/amino acids. .................. Y................. ........... ........... ........... ........... ...........
B4154.............. EF spec metabolic .................. Y................. ........... ........... ........... ........... ...........
noninherit.
[[Page 67116]]
B4155.............. EF incomplete/modular..... .................. Y................. ........... ........... ........... ........... ...........
B4157.............. EF special metabolic .................. Y................. ........... ........... ........... ........... ...........
inherit.
B4158.............. EF ped complete intact nut .................. Y................. ........... ........... ........... ........... ...........
B4159.............. EF ped complete soy based. .................. Y................. ........... ........... ........... ........... ...........
B4160.............. EF ped caloric dense>/ .................. Y................. ........... ........... ........... ........... ...........
=0.7kc.
B4161.............. EF ped hydrolyzed/amino .................. Y................. ........... ........... ........... ........... ...........
acid.
B4162.............. EF ped specmetabolic .................. Y................. ........... ........... ........... ........... ...........
inherit.
B4164.............. Parenteral 50% dextrose .................. Y................. ........... ........... ........... ........... ...........
solu.
B4168.............. Parenteral sol amino acid .................. Y................. ........... ........... ........... ........... ...........
3..
B4172.............. Parenteral sol amino acid .................. Y................. ........... ........... ........... ........... ...........
5..
B4176.............. Parenteral sol amino acid .................. Y................. ........... ........... ........... ........... ...........
7-.
B4178.............. Parenteral sol amino acid .................. Y................. ........... ........... ........... ........... ...........
>.
B4180.............. Parenteral sol carb > 50%. .................. Y................. ........... ........... ........... ........... ...........
B4185.............. Parenteral sol 10 gm .................. B................. ........... ........... ........... ........... ...........
lipids.
B4189.............. Parenteral sol amino acid .................. Y................. ........... ........... ........... ........... ...........
&.
B4193.............. Parenteral sol 52-73 gm .................. Y................. ........... ........... ........... ........... ...........
prot.
B4197.............. Parenteral sol 74-100 gm .................. Y................. ........... ........... ........... ........... ...........
pro.
B4199.............. Parenteral sol > 100gm .................. Y................. ........... ........... ........... ........... ...........
prote.
B4216.............. Parenteral nutrition .................. Y................. ........... ........... ........... ........... ...........
additiv.
B4220.............. Parenteral supply kit .................. Y................. ........... ........... ........... ........... ...........
premix.
B4222.............. Parenteral supply kit .................. Y................. ........... ........... ........... ........... ...........
homemi.
B4224.............. Parenteral administration .................. Y................. ........... ........... ........... ........... ...........
ki.
B5000.............. Parenteral sol renal- .................. Y................. ........... ........... ........... ........... ...........
amirosy.
B5100.............. Parenteral sol hepatic- .................. Y................. ........... ........... ........... ........... ...........
fream.
B5200.............. Parenteral sol stres-brnch .................. Y................. ........... ........... ........... ........... ...........
c.
B9000.............. Enter infusion pump w/o .................. Y................. ........... ........... ........... ........... ...........
alrm.
B9002.............. Enteral infusion pump w/ .................. Y................. ........... ........... ........... ........... ...........
ala.
B9004.............. Parenteral infus pump .................. Y................. ........... ........... ........... ........... ...........
portab.
B9006.............. Parenteral infus pump .................. Y................. ........... ........... ........... ........... ...........
statio.
B9998.............. Enteral supp not otherwise .................. Y................. ........... ........... ........... ........... ...........
c.
B9999.............. Parenteral supp not othrws .................. Y................. ........... ........... ........... ........... ...........
c.
C1300.............. HYPERBARIC Oxygen......... .................. S................. 0659 1.5579 $99.23 ........... $19.85
C1713.............. Anchor/screw bn/bn,tis/bn. .................. N................. ........... ........... ........... ........... ...........
C1714.............. Cath, trans atherectomy, .................. N................. ........... ........... ........... ........... ...........
dir.
C1715.............. Brachytherapy needle...... .................. N................. ........... ........... ........... ........... ...........
C1716.............. Brachytx, non-str, Gold- CH................ K................. 1716 0.5228 $33.30 ........... $6.66
198.
C1717.............. Brachytx, non-str,HDR Ir- CH................ K................. 1717 2.7505 $175.19 ........... $35.04
192.
C1719.............. Brachytx, NS, Non-HDRIr- CH................ K................. 1719 1.0226 $65.13 ........... $13.03
192.
C1721.............. AICD, dual chamber........ .................. N................. ........... ........... ........... ........... ...........
C1722.............. AICD, single chamber...... .................. N................. ........... ........... ........... ........... ...........
C1724.............. Cath, trans .................. N................. ........... ........... ........... ........... ...........
atherec,rotation.
C1725.............. Cath, translumin non-laser .................. N................. ........... ........... ........... ........... ...........
C1726.............. Cath, bal dil, non- .................. N................. ........... ........... ........... ........... ...........
vascular.
C1727.............. Cath, bal tis dis, non-vas .................. N................. ........... ........... ........... ........... ...........
C1728.............. Cath, brachytx seed adm... .................. N................. ........... ........... ........... ........... ...........
C1729.............. Cath, drainage............ .................. N................. ........... ........... ........... ........... ...........
C1730.............. Cath, EP, 19 or few elect. .................. N................. ........... ........... ........... ........... ...........
C1731.............. Cath, EP, 20 or more elec. .................. N................. ........... ........... ........... ........... ...........
C1732.............. Cath, EP, diag/abl, 3D/ .................. N................. ........... ........... ........... ........... ...........
vect.
C1733.............. Cath, EP, othr than cool- .................. N................. ........... ........... ........... ........... ...........
tip.
C1750.............. Cath, hemodialysis,long- .................. N................. ........... ........... ........... ........... ...........
term.
C1751.............. Cath, inf, per/cent/ .................. N................. ........... ........... ........... ........... ...........
midline.
C1752.............. Cath,hemodialysis,short- .................. N................. ........... ........... ........... ........... ...........
term.
C1753.............. Cath, intravas ultrasound. .................. N................. ........... ........... ........... ........... ...........
C1754.............. Catheter, intradiscal..... .................. N................. ........... ........... ........... ........... ...........
C1755.............. Catheter, intraspinal..... .................. N................. ........... ........... ........... ........... ...........
C1756.............. Cath, pacing, transesoph.. .................. N................. ........... ........... ........... ........... ...........
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, cardiac... .................. N................. ........... ........... ........... ........... ...........
C1765.............. Adhesion barrier.......... .................. N................. ........... ........... ........... ........... ...........
C1766.............. Intro/sheath,strble,non- .................. N................. ........... ........... ........... ........... ...........
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/sling. .................. N................. ........... ........... ........... ........... ...........
C1772.............. Infusion pump, .................. N................. ........... ........... ........... ........... ...........
programmable.
C1773.............. Ret dev, insertable....... .................. N................. ........... ........... ........... ........... ...........
C1776.............. Joint device (implantable) .................. N................. ........... ........... ........... ........... ...........
C1777.............. Lead, AICD, endo single .................. N................. ........... ........... ........... ........... ...........
coil.
C1778.............. Lead, neurostimulator..... .................. N................. ........... ........... ........... ........... ...........
C1779.............. Lead, pmkr, transvenous .................. N................. ........... ........... ........... ........... ...........
VDD.
C1780.............. Lens, intraocular (new .................. N................. ........... ........... ........... ........... ...........
tech).
C1781.............. Mesh (implantable)........ .................. N................. ........... ........... ........... ........... ...........
C1782.............. Morcellator............... .................. N................. ........... ........... ........... ........... ...........
[[Page 67117]]
C1783.............. Ocular imp, aqueous drain .................. N................. ........... ........... ........... ........... ...........
de.
C1784.............. Ocular dev, intraop, det .................. N................. ........... ........... ........... ........... ...........
ret.
C1785.............. Pmkr, dual, rate-resp..... .................. N................. ........... ........... ........... ........... ...........
C1786.............. Pmkr, single, rate-resp... .................. N................. ........... ........... ........... ........... ...........
C1787.............. Patient progr, neurostim.. .................. N................. ........... ........... ........... ........... ...........
C1788.............. Port, indwelling, imp..... .................. N................. ........... ........... ........... ........... ...........
C1789.............. Prosthesis, breast, imp... .................. N................. ........... ........... ........... ........... ...........
C1813.............. Prosthesis, penile, .................. N................. ........... ........... ........... ........... ...........
inflatab.
C1814.............. Retinal tamp, silicone oil .................. N................. ........... ........... ........... ........... ...........
C1815.............. Pros, urinary sph, imp.... .................. N................. ........... ........... ........... ........... ...........
C1816.............. Receiver/transmitter, .................. N................. ........... ........... ........... ........... ...........
neuro.
C1817.............. Septal defect imp sys..... .................. N................. ........... ........... ........... ........... ...........
C1818.............. Integrated .................. N................. ........... ........... ........... ........... ...........
keratoprosthesis.
C1819.............. Tissue localization- .................. N................. ........... ........... ........... ........... ...........
excision.
C1820.............. Generator neuro rechg bat CH................ N................. ........... ........... ........... ........... ...........
sy.
C1821.............. Interspinous implant...... .................. H................. 1821 ........... ........... ........... ...........
C1874.............. Stent, coated/cov w/del .................. N................. ........... ........... ........... ........... ...........
sys.
C1875.............. Stent, coated/cov w/o del .................. N................. ........... ........... ........... ........... ...........
sy.
C1876.............. Stent, non-coa/non-cov w/ .................. N................. ........... ........... ........... ........... ...........
del.
C1877.............. Stent, non-coat/cov w/o .................. N................. ........... ........... ........... ........... ...........
del.
C1878.............. Matrl for vocal cord...... .................. N................. ........... ........... ........... ........... ...........
C1879.............. Tissue marker, implantable .................. N................. ........... ........... ........... ........... ...........
C1880.............. Vena cava filter.......... .................. N................. ........... ........... ........... ........... ...........
C1881.............. Dialysis access system.... .................. N................. ........... ........... ........... ........... ...........
C1882.............. AICD, other than sing/dual .................. N................. ........... ........... ........... ........... ...........
C1883.............. Adapt/ext, pacing/neuro .................. N................. ........... ........... ........... ........... ...........
lead.
C1884.............. Embolization Protect syst. .................. N................. ........... ........... ........... ........... ...........
C1885.............. Cath, translumin angio .................. N................. ........... ........... ........... ........... ...........
laser.
C1887.............. Catheter, guiding......... .................. N................. ........... ........... ........... ........... ...........
C1888.............. Endovas non-cardiac abl .................. N................. ........... ........... ........... ........... ...........
cath.
C1891.............. Infusion pump,non-prog, .................. N................. ........... ........... ........... ........... ...........
perm.
C1892.............. Intro/sheath,fixed,peel- .................. N................. ........... ........... ........... ........... ...........
away.
C1893.............. Intro/sheath, fixed,non- .................. N................. ........... ........... ........... ........... ...........
peel.
C1894.............. Intro/sheath, non-laser... .................. N................. ........... ........... ........... ........... ...........
C1895.............. Lead, AICD, endo dual coil .................. N................. ........... ........... ........... ........... ...........
C1896.............. Lead, AICD, non sing/dual. .................. N................. ........... ........... ........... ........... ...........
C1897.............. Lead, neurostim test kit.. .................. N................. ........... ........... ........... ........... ...........
C1898.............. Lead, pmkr, other than .................. N................. ........... ........... ........... ........... ...........
trans.
C1899.............. Lead, pmkr/AICD .................. N................. ........... ........... ........... ........... ...........
combination.
C1900.............. Lead, coronary venous..... .................. N................. ........... ........... ........... ........... ...........
C2614.............. Probe, perc lumb disc..... .................. N................. ........... ........... ........... ........... ...........
C2615.............. Sealant, pulmonary, liquid .................. N................. ........... ........... ........... ........... ...........
C2616.............. Brachytx, non-str,Yttrium- CH................ K................. 2616 184.7105 $11,764.95 ........... $2,352.99
90.
C2617.............. Stent, non-cor, tem w/o .................. N................. ........... ........... ........... ........... ...........
del.
C2618.............. Probe, cryoablation....... .................. N................. ........... ........... ........... ........... ...........
C2619.............. Pmkr, dual, non rate-resp. .................. N................. ........... ........... ........... ........... ...........
C2620.............. Pmkr, single, non rate- .................. N................. ........... ........... ........... ........... ...........
resp.
C2621.............. Pmkr, other than sing/dual .................. N................. ........... ........... ........... ........... ...........
C2622.............. Prosthesis, penile, non- .................. N................. ........... ........... ........... ........... ...........
inf.
C2625.............. Stent, non-cor, tem w/del .................. N................. ........... ........... ........... ........... ...........
sy.
C2626.............. Infusion pump, non- .................. N................. ........... ........... ........... ........... ...........
prog,temp.
C2627.............. Cath, suprapubic/ .................. N................. ........... ........... ........... ........... ...........
cystoscopic.
C2628.............. Catheter, occlusion....... .................. N................. ........... ........... ........... ........... ...........
C2629.............. Intro/sheath, laser....... .................. N................. ........... ........... ........... ........... ...........
C2630.............. Cath, EP, cool-tip........ .................. N................. ........... ........... ........... ........... ...........
C2631.............. Rep dev, urinary, w/o .................. N................. ........... ........... ........... ........... ...........
sling.
C2634.............. Brachytx, non-str, HA, I- CH................ K................. 2634 0.4858 $30.94 ........... $6.19
125.
C2635.............. Brachytx, non-str, HA, P- CH................ K................. 2635 0.7366 $46.92 ........... $9.38
103.
C2636.............. Brachy linear, non-str,P- CH................ K................. 2636 0.6600 $42.04 ........... $8.41
103.
C2637.............. Brachy,non-str,Ytterbium- CH................ B................. ........... ........... ........... ........... ...........
169.
C2638.............. Brachytx, stranded, I-125. NF................ K................. 2638 0.7113 $45.31 ........... $9.06
C2639.............. Brachytx, non-stranded,I- NF................ K................. 2639 0.5039 $32.10 ........... $6.42
125.
C2640.............. Brachytx, stranded, P-103. NF................ K................. 2640 1.0308 $65.66 ........... $13.13
C2641.............. Brachytx, non-stranded,P- NF................ K................. 2641 0.8077 $51.45 ........... $10.29
103.
C2642.............. Brachytx, stranded, C-131. NF................ K................. 2642 1.5342 $97.72 ........... $19.54
C2643.............. Brachytx, non-stranded,C- NF................ K................. 2643 1.0060 $64.08 ........... $12.82
131.
C2698.............. Brachytx, stranded, NOS... NF................ K................. 2698 0.7113 $45.31 ........... $9.06
C2699.............. Brachytx, non-stranded, NF................ K................. 2699 0.4858 $30.94 ........... $6.19
NOS.
C8900.............. MRA w/cont, abd........... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
C8901.............. MRA w/o cont, abd......... .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
C8902.............. MRA w/o fol w/cont, abd... .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
C8903.............. MRI w/cont, breast, uni... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
C8904.............. MRI w/o cont, breast, uni. .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
C8905.............. MRI w/o fol w/cont, brst, .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
un.
C8906.............. MRI w/cont, breast, bi.... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
C8907.............. MRI w/o cont, breast, bi.. .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
C8908.............. MRI w/o fol w/cont, .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
breast,.
C8909.............. MRA w/cont, chest......... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
C8910.............. MRA w/o cont, chest....... .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
C8911.............. MRA w/o fol w/cont, chest. .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
[[Page 67118]]
C8912.............. MRA w/cont, lwr ext....... .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
C8913.............. MRA w/o cont, lwr ext..... .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
C8914.............. MRA w/o fol w/cont, lwr .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
ext.
C8918.............. MRA w/cont, pelvis........ .................. S................. 0284 6.2350 $397.13 $148.40 $79.43
C8919.............. MRA w/o cont, pelvis...... .................. S................. 0336 5.3933 $343.52 $137.40 $68.70
C8920.............. MRA w/o fol w/cont, pelvis .................. S................. 0337 8.2463 $525.24 $199.53 $105.05
C8921.............. Comp transtho echo w/contr NI................ S................. 0128 8.4896 $540.74 $216.29 $108.15
C8922.............. Limit transtho echo w/ NI................ S................. 0128 8.4896 $540.74 $216.29 $108.15
contr.
C8923.............. 2D com transtho echo w/ NI................ S................. 0128 8.4896 $540.74 $216.29 $108.15
contr.
C8924.............. 2D lim transtho echo w/ NI................ S................. 0128 8.4896 $540.74 $216.29 $108.15
contr.
C8925.............. 2D TEE w/contrast, int/ NI................ S................. 0128 8.4896 $540.74 $216.29 $108.15
rept.
C8926.............. Cong TEE w/contr, int/rept NI................ S................. 0128 8.4896 $540.74 $216.29 $108.15
C8927.............. TEE w/contrast; monitor... NI................ S................. 0128 8.4896 $540.74 $216.29 $108.15
C8928.............. 2D transtho w/contr; NI................ S................. 0128 8.4896 $540.74 $216.29 $108.15
stress.
C8957.............. Prolonged IV inf, req pump .................. S................. 0441 2.3446 $149.34 ........... $29.87
C9003.............. Palivizumab, per 50 mg.... .................. K................. 9003 ........... $810.67 ........... $162.13
C9113.............. Inj pantoprazole sodium, .................. N................. ........... ........... ........... ........... ...........
via.
C9121.............. Injection, argatroban..... .................. K................. 9121 ........... $18.96 ........... $3.79
C9232.............. Injection, idursulfase.... CH................ D................. ........... ........... ........... ........... ...........
C9233.............. Injection, ranibizumab.... CH................ D................. ........... ........... ........... ........... ...........
C9234.............. Inj, alglucosidase alfa... CH................ D................. ........... ........... ........... ........... ...........
C9235.............. Injection, panitumumab.... CH................ D................. ........... ........... ........... ........... ...........
C9236.............. Injection, eculizumab..... CH................ D................. ........... ........... ........... ........... ...........
C9238.............. Inj, levetiracetam........ NI................ K................. 9238 ........... $6.30 ........... $1.26
C9239.............. Inj, temsirolimus......... NI................ G................. 1168 ........... $48.41 ........... $9.68
C9350.............. Porous collagen tube per CH................ D................. ........... ........... ........... ........... ...........
cm.
C9351.............. Acellular derm tissue CH................ D................. ........... ........... ........... ........... ...........
percm2.
C9352.............. Neuragen nerve guide, per NI................ G................. 9350 ........... $482.56 ........... $96.51
cm.
C9353.............. Neurawrap nerve NI................ G................. 1169 ........... $482.56 ........... $96.51
protector,cm.
C9399.............. Unclassified drugs or .................. A................. ........... ........... ........... ........... ...........
biolog.
C9716.............. Radiofrequency energy to .................. T................. 0150 30.1606 $1,921.05 $437.12 $384.21
anu.
C9723.............. Dyn IR Perf Img........... .................. S................. 1502 ........... $75.00 ........... $15.00
C9724.............. EPS gast cardia plic...... .................. T................. 0422 25.3233 $1,612.94 $448.81 $322.59
C9725.............. Place endorectal app...... .................. S................. 1507 ........... $550.00 ........... $110.00
C9726.............. Rxt breast appl place/ .................. S................. 1508 ........... $650.00 ........... $130.00
remov.
C9727.............. Insert palate implants.... .................. S................. 1510 ........... $850.00 ........... $170.00
C9728.............. Place device/marker, non NF................ T................. 0156 3.0469 $194.07 ........... $38.81
pro.
D0120.............. Periodic oral evaluation.. .................. E................. ........... ........... ........... ........... ...........
D0140.............. Limit oral eval problm .................. E................. ........... ........... ........... ........... ...........
focus.
D0145.............. Oral evaluation, pt < 3yrs .................. E................. ........... ........... ........... ........... ...........
D0150.............. Comprehensve oral .................. S................. 0330 9.1677 $583.93 ........... $116.79
evaluation.
D0160.............. Extensv oral eval prob .................. E................. ........... ........... ........... ........... ...........
focus.
D0170.............. Re-eval,est pt,problem .................. E................. ........... ........... ........... ........... ...........
focus.
D0180.............. Comp periodontal .................. E................. ........... ........... ........... ........... ...........
evaluation.
D0210.............. Intraor complete film .................. E................. ........... ........... ........... ........... ...........
series.
D0220.............. Intraoral periapical first .................. E................. ........... ........... ........... ........... ...........
f.
D0230.............. Intraoral periapical ea .................. E................. ........... ........... ........... ........... ...........
add.
D0240.............. Intraoral occlusal film... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D0250.............. Extraoral first film...... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D0260.............. Extraoral ea additional .................. S................. 0330 9.1677 $583.93 ........... $116.79
film.
D0270.............. Dental bitewing single .................. S................. 0330 9.1677 $583.93 ........... $116.79
film.
D0272.............. Dental bitewings two films .................. S................. 0330 9.1677 $583.93 ........... $116.79
D0273.............. Bitewings - three films... .................. E................. ........... ........... ........... ........... ...........
D0274.............. Dental bitewings four .................. S................. 0330 9.1677 $583.93 ........... $116.79
films.
D0277.............. Vert bitewings-sev to .................. S................. 0330 9.1677 $583.93 ........... $116.79
eight.
D0290.............. Dental film skull/facial .................. E................. ........... ........... ........... ........... ...........
bon.
D0310.............. Dental saliography........ .................. E................. ........... ........... ........... ........... ...........
D0320.............. Dental tmj arthrogram incl .................. E................. ........... ........... ........... ........... ...........
i.
D0321.............. Dental other tmj films.... .................. E................. ........... ........... ........... ........... ...........
D0322.............. Dental tomographic survey. .................. E................. ........... ........... ........... ........... ...........
D0330.............. Dental panoramic film..... .................. E................. ........... ........... ........... ........... ...........
D0340.............. Dental cephalometric film. .................. E................. ........... ........... ........... ........... ...........
D0350.............. Oral/facial photo images.. .................. E................. ........... ........... ........... ........... ...........
D0360.............. Cone beam ct.............. .................. E................. ........... ........... ........... ........... ...........
D0362.............. Cone beam, two dimensional .................. E................. ........... ........... ........... ........... ...........
D0363.............. Cone beam, three .................. E................. ........... ........... ........... ........... ...........
dimensional.
D0415.............. Collection of .................. E................. ........... ........... ........... ........... ...........
microorganisms.
D0416.............. Viral culture............. .................. B................. ........... ........... ........... ........... ...........
D0421.............. Gen tst suscept oral .................. B................. ........... ........... ........... ........... ...........
disease.
D0425.............. Caries susceptibility test .................. E................. ........... ........... ........... ........... ...........
D0431.............. Diag tst detect mucos .................. B................. ........... ........... ........... ........... ...........
abnorm.
D0460.............. Pulp vitality test........ .................. S................. 0330 9.1677 $583.93 ........... $116.79
D0470.............. Diagnostic casts.......... .................. E................. ........... ........... ........... ........... ...........
D0472.............. Gross exam, prep & report. .................. B................. ........... ........... ........... ........... ...........
D0473.............. Micro exam, prep & report. .................. B................. ........... ........... ........... ........... ...........
D0474.............. Micro w exam of surg .................. B................. ........... ........... ........... ........... ...........
margins.
D0475.............. Decalcification procedure. .................. B................. ........... ........... ........... ........... ...........
D0476.............. Spec stains for .................. B................. ........... ........... ........... ........... ...........
microorganis.
D0477.............. Spec stains not for .................. B................. ........... ........... ........... ........... ...........
microorg.
D0478.............. Immunohistochemical stains .................. B................. ........... ........... ........... ........... ...........
[[Page 67119]]
D0479.............. Tissue in-situ .................. B................. ........... ........... ........... ........... ...........
hybridization.
D0480.............. Cytopath smear prep & .................. B................. ........... ........... ........... ........... ...........
report.
D0481.............. Electron microscopy .................. B................. ........... ........... ........... ........... ...........
diagnost.
D0482.............. Direct immunofluorescence. .................. B................. ........... ........... ........... ........... ...........
D0483.............. Indirect .................. B................. ........... ........... ........... ........... ...........
immunofluorescence.
D0484.............. Consult slides prep .................. B................. ........... ........... ........... ........... ...........
elsewher.
D0485.............. Consult inc prep of slides .................. B................. ........... ........... ........... ........... ...........
D0486.............. Accession of brush biopsy. .................. E................. ........... ........... ........... ........... ...........
D0502.............. Other oral pathology .................. B................. ........... ........... ........... ........... ...........
procedu.
D0999.............. Unspecified diagnostic .................. B................. ........... ........... ........... ........... ...........
proce.
D1110.............. Dental prophylaxis adult.. .................. E................. ........... ........... ........... ........... ...........
D1120.............. Dental prophylaxis child.. .................. E................. ........... ........... ........... ........... ...........
D1203.............. Topical fluor w/o prophy .................. E................. ........... ........... ........... ........... ...........
chi.
D1204.............. Topical fluor w/o prophy .................. E................. ........... ........... ........... ........... ...........
adu.
D1206.............. Topical fluoride varnish.. .................. E................. ........... ........... ........... ........... ...........
D1310.............. Nutri counsel-control .................. E................. ........... ........... ........... ........... ...........
caries.
D1320.............. Tobacco counseling........ .................. E................. ........... ........... ........... ........... ...........
D1330.............. Oral hygiene instruction.. .................. E................. ........... ........... ........... ........... ...........
D1351.............. Dental sealant per tooth.. .................. E................. ........... ........... ........... ........... ...........
D1510.............. Space maintainer fxd .................. S................. 0330 9.1677 $583.93 ........... $116.79
unilat.
D1515.............. Fixed bilat space .................. S................. 0330 9.1677 $583.93 ........... $116.79
maintainer.
D1520.............. Remove unilat space .................. S................. 0330 9.1677 $583.93 ........... $116.79
maintain.
D1525.............. Remove bilat space .................. S................. 0330 9.1677 $583.93 ........... $116.79
maintain.
D1550.............. Recement space maintainer. .................. S................. 0330 9.1677 $583.93 ........... $116.79
D1555.............. Remove fix space .................. E................. ........... ........... ........... ........... ...........
maintainer.
D2140.............. Amalgam one surface .................. E................. ........... ........... ........... ........... ...........
permanen.
D2150.............. Amalgam two surfaces .................. E................. ........... ........... ........... ........... ...........
permane.
D2160.............. Amalgam three surfaces .................. E................. ........... ........... ........... ........... ...........
perma.
D2161.............. Amalgam 4 or > surfaces .................. E................. ........... ........... ........... ........... ...........
perm.
D2330.............. Resin one surface-anterior .................. E................. ........... ........... ........... ........... ...........
D2331.............. Resin two surfaces- .................. E................. ........... ........... ........... ........... ...........
anterior.
D2332.............. Resin three surfaces- .................. E................. ........... ........... ........... ........... ...........
anterio.
D2335.............. Resin 4/> surf or w incis .................. E................. ........... ........... ........... ........... ...........
an.
D2390.............. Ant resin-based cmpst .................. E................. ........... ........... ........... ........... ...........
crown.
D2391.............. Post 1 srfc resinbased .................. E................. ........... ........... ........... ........... ...........
cmpst.
D2392.............. Post 2 srfc resinbased .................. E................. ........... ........... ........... ........... ...........
cmpst.
D2393.............. Post 3 srfc resinbased .................. E................. ........... ........... ........... ........... ...........
cmpst.
D2394.............. Post >=4srfc resinbase .................. E................. ........... ........... ........... ........... ...........
cmpst.
D2410.............. Dental gold foil one .................. E................. ........... ........... ........... ........... ...........
surface.
D2420.............. Dental gold foil two .................. E................. ........... ........... ........... ........... ...........
surface.
D2430.............. Dental gold foil three .................. E................. ........... ........... ........... ........... ...........
surfa.
D2510.............. Dental inlay metalic 1 .................. E................. ........... ........... ........... ........... ...........
surf.
D2520.............. Dental inlay metallic 2 .................. E................. ........... ........... ........... ........... ...........
surf.
D2530.............. Dental inlay metl 3/more .................. E................. ........... ........... ........... ........... ...........
sur.
D2542.............. Dental onlay metallic 2 .................. E................. ........... ........... ........... ........... ...........
surf.
D2543.............. Dental onlay metallic 3 .................. E................. ........... ........... ........... ........... ...........
surf.
D2544.............. Dental onlay metl 4/more .................. E................. ........... ........... ........... ........... ...........
sur.
D2610.............. Inlay porcelain/ceramic 1 .................. E................. ........... ........... ........... ........... ...........
su.
D2620.............. Inlay porcelain/ceramic 2 .................. E................. ........... ........... ........... ........... ...........
su.
D2630.............. Dental onlay porc 3/more .................. E................. ........... ........... ........... ........... ...........
sur.
D2642.............. Dental onlay porcelin 2 .................. E................. ........... ........... ........... ........... ...........
surf.
D2643.............. Dental onlay porcelin 3 .................. E................. ........... ........... ........... ........... ...........
surf.
D2644.............. Dental onlay porc 4/more .................. E................. ........... ........... ........... ........... ...........
sur.
D2650.............. Inlay composite/resin one .................. E................. ........... ........... ........... ........... ...........
su.
D2651.............. Inlay composite/resin two .................. E................. ........... ........... ........... ........... ...........
su.
D2652.............. Dental inlay resin 3/mre .................. E................. ........... ........... ........... ........... ...........
sur.
D2662.............. Dental onlay resin 2 .................. E................. ........... ........... ........... ........... ...........
surface.
D2663.............. Dental onlay resin 3 .................. E................. ........... ........... ........... ........... ...........
surface.
D2664.............. Dental onlay resin 4/mre .................. E................. ........... ........... ........... ........... ...........
sur.
D2710.............. Crown resin-based indirect .................. E................. ........... ........... ........... ........... ...........
D2712.............. Crown 3/4 resin-based .................. E................. ........... ........... ........... ........... ...........
compos.
D2720.............. Crown resin w/ high noble .................. E................. ........... ........... ........... ........... ...........
me.
D2721.............. Crown resin w/ base metal. .................. E................. ........... ........... ........... ........... ...........
D2722.............. Crown resin w/ noble metal .................. E................. ........... ........... ........... ........... ...........
D2740.............. Crown porcelain/ceramic .................. E................. ........... ........... ........... ........... ...........
subs.
D2750.............. Crown porcelain w/ h noble .................. E................. ........... ........... ........... ........... ...........
m.
D2751.............. Crown porcelain fused base .................. E................. ........... ........... ........... ........... ...........
m.
D2752.............. Crown porcelain w/ noble .................. E................. ........... ........... ........... ........... ...........
met.
D2780.............. Crown 3/4 cast hi noble .................. E................. ........... ........... ........... ........... ...........
met.
D2781.............. Crown 3/4 cast base metal. .................. E................. ........... ........... ........... ........... ...........
D2782.............. Crown 3/4 cast noble metal .................. E................. ........... ........... ........... ........... ...........
D2783.............. Crown 3/4 porcelain/ .................. E................. ........... ........... ........... ........... ...........
ceramic.
D2790.............. Crown full cast high noble .................. E................. ........... ........... ........... ........... ...........
m.
D2791.............. Crown full cast base metal .................. E................. ........... ........... ........... ........... ...........
D2792.............. Crown full cast noble .................. E................. ........... ........... ........... ........... ...........
metal.
D2794.............. Crown-titanium............ .................. E................. ........... ........... ........... ........... ...........
D2799.............. Provisional crown......... .................. E................. ........... ........... ........... ........... ...........
D2910.............. Recement inlay onlay or .................. E................. ........... ........... ........... ........... ...........
part.
D2915.............. Recement cast or prefab .................. E................. ........... ........... ........... ........... ...........
post.
D2920.............. Dental recement crown..... .................. E................. ........... ........... ........... ........... ...........
[[Page 67120]]
D2930.............. Prefab stnlss steel crwn .................. E................. ........... ........... ........... ........... ...........
pri.
D2931.............. Prefab stnlss steel crown .................. E................. ........... ........... ........... ........... ...........
pe.
D2932.............. Prefabricated resin crown. .................. E................. ........... ........... ........... ........... ...........
D2933.............. Prefab stainless steel .................. E................. ........... ........... ........... ........... ...........
crown.
D2934.............. Prefab steel crown primary .................. E................. ........... ........... ........... ........... ...........
D2940.............. Dental sedative filling... .................. E................. ........... ........... ........... ........... ...........
D2950.............. Core build-up incl any .................. E................. ........... ........... ........... ........... ...........
pins.
D2951.............. Tooth pin retention....... .................. E................. ........... ........... ........... ........... ...........
D2952.............. Post and core cast + crown .................. E................. ........... ........... ........... ........... ...........
D2953.............. Each addtnl cast post..... .................. E................. ........... ........... ........... ........... ...........
D2954.............. Prefab post/core + crown.. .................. E................. ........... ........... ........... ........... ...........
D2955.............. Post removal.............. .................. E................. ........... ........... ........... ........... ...........
D2957.............. Each addtnl prefab post... .................. E................. ........... ........... ........... ........... ...........
D2960.............. Laminate labial veneer.... .................. E................. ........... ........... ........... ........... ...........
D2961.............. Lab labial veneer resin... .................. E................. ........... ........... ........... ........... ...........
D2962.............. Lab labial veneer .................. E................. ........... ........... ........... ........... ...........
porcelain.
D2970.............. Temp crown (fractured .................. E................. ........... ........... ........... ........... ...........
tooth).
D2971.............. Add proc construct new .................. E................. ........... ........... ........... ........... ...........
crown.
D2975.............. Coping.................... .................. E................. ........... ........... ........... ........... ...........
D2980.............. Crown repair.............. .................. E................. ........... ........... ........... ........... ...........
D2999.............. Dental unspec restorative .................. S................. 0330 9.1677 $583.93 ........... $116.79
pr.
D3110.............. Pulp cap direct........... .................. E................. ........... ........... ........... ........... ...........
D3120.............. Pulp cap indirect......... .................. E................. ........... ........... ........... ........... ...........
D3220.............. Therapeutic pulpotomy..... .................. E................. ........... ........... ........... ........... ...........
D3221.............. Gross pulpal debridement.. .................. E................. ........... ........... ........... ........... ...........
D3230.............. Pulpal therapy anterior .................. E................. ........... ........... ........... ........... ...........
prim.
D3240.............. Pulpal therapy posterior .................. E................. ........... ........... ........... ........... ...........
pri.
D3310.............. Anterior.................. .................. E................. ........... ........... ........... ........... ...........
D3320.............. Root canal therapy 2 .................. E................. ........... ........... ........... ........... ...........
canals.
D3330.............. Root canal therapy 3 .................. E................. ........... ........... ........... ........... ...........
canals.
D3331.............. Non-surg tx root canal obs .................. E................. ........... ........... ........... ........... ...........
D3332.............. Incomplete endodontic tx.. .................. E................. ........... ........... ........... ........... ...........
D3333.............. Internal root repair...... .................. E................. ........... ........... ........... ........... ...........
D3346.............. Retreat root canal .................. E................. ........... ........... ........... ........... ...........
anterior.
D3347.............. Retreat root canal .................. E................. ........... ........... ........... ........... ...........
bicuspid.
D3348.............. Retreat root canal molar.. .................. E................. ........... ........... ........... ........... ...........
D3351.............. Apexification/recalc .................. E................. ........... ........... ........... ........... ...........
initial.
D3352.............. Apexification/recalc .................. E................. ........... ........... ........... ........... ...........
interim.
D3353.............. Apexification/recalc final .................. E................. ........... ........... ........... ........... ...........
D3410.............. Apicoect/perirad surg .................. E................. ........... ........... ........... ........... ...........
anter.
D3421.............. Root surgery bicuspid..... .................. E................. ........... ........... ........... ........... ...........
D3425.............. Root surgery molar........ .................. E................. ........... ........... ........... ........... ...........
D3426.............. Root surgery ea add root.. .................. E................. ........... ........... ........... ........... ...........
D3430.............. Retrograde filling........ .................. E................. ........... ........... ........... ........... ...........
D3450.............. Root amputation........... .................. E................. ........... ........... ........... ........... ...........
D3460.............. Endodontic endosseous .................. S................. 0330 9.1677 $583.93 ........... $116.79
implan.
D3470.............. Intentional replantation.. .................. E................. ........... ........... ........... ........... ...........
D3910.............. Isolation- tooth w rubb .................. E................. ........... ........... ........... ........... ...........
dam.
D3920.............. Tooth splitting........... .................. E................. ........... ........... ........... ........... ...........
D3950.............. Canal prep/fitting of .................. E................. ........... ........... ........... ........... ...........
dowel.
D3999.............. Endodontic procedure...... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D4210.............. Gingivectomy/plasty per .................. E................. ........... ........... ........... ........... ...........
quad.
D4211.............. Gingivectomy/plasty per .................. E................. ........... ........... ........... ........... ...........
toot.
D4230.............. Ana crown exp 4 or> per .................. E................. ........... ........... ........... ........... ...........
quad.
D4231.............. Ana crown exp 1-3 per quad .................. E................. ........... ........... ........... ........... ...........
D4240.............. Gingival flap proc w/ .................. E................. ........... ........... ........... ........... ...........
planin.
D4241.............. Gngvl flap w rootplan 1-3 .................. E................. ........... ........... ........... ........... ...........
th.
D4245.............. Apically positioned flap.. .................. E................. ........... ........... ........... ........... ...........
D4249.............. Crown lengthen hard tissue .................. E................. ........... ........... ........... ........... ...........
D4260.............. Osseous surgery per .................. S................. 0330 9.1677 $583.93 ........... $116.79
quadrant.
D4261.............. Osseous surgl- .................. E................. ........... ........... ........... ........... ...........
3teethperquad.
D4263.............. Bone replce graft first .................. S................. 0330 9.1677 $583.93 ........... $116.79
site.
D4264.............. Bone replce graft each add .................. S................. 0330 9.1677 $583.93 ........... $116.79
D4265.............. Bio mtrls to aid soft/os .................. E................. ........... ........... ........... ........... ...........
reg.
D4266.............. Guided tiss regen resorble .................. E................. ........... ........... ........... ........... ...........
D4267.............. Guided tiss regen .................. E................. ........... ........... ........... ........... ...........
nonresorb.
D4268.............. Surgical revision .................. S................. 0330 9.1677 $583.93 ........... $116.79
procedure.
D4270.............. Pedicle soft tissue graft .................. S................. 0330 9.1677 $583.93 ........... $116.79
pr.
D4271.............. Free soft tissue graft .................. S................. 0330 9.1677 $583.93 ........... $116.79
proc.
D4273.............. Subepithelial tissue graft .................. S................. 0330 9.1677 $583.93 ........... $116.79
D4274.............. Distal/proximal wedge proc .................. E................. ........... ........... ........... ........... ...........
D4275.............. Soft tissue allograft..... .................. E................. ........... ........... ........... ........... ...........
D4276.............. Con tissue w dble ped .................. E................. ........... ........... ........... ........... ...........
graft.
D4320.............. Provision splnt .................. E................. ........... ........... ........... ........... ...........
intracoronal.
D4321.............. Provisional splint .................. E................. ........... ........... ........... ........... ...........
extracoro.
D4341.............. Periodontal scaling & root .................. E................. ........... ........... ........... ........... ...........
D4342.............. Periodontal scaling 1- .................. E................. ........... ........... ........... ........... ...........
3teeth.
D4355.............. Full mouth debridement.... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D4381.............. Localized delivery .................. S................. 0330 9.1677 $583.93 ........... $116.79
antimicro.
D4910.............. Periodontal maint .................. E................. ........... ........... ........... ........... ...........
procedures.
[[Page 67121]]
D4920.............. Unscheduled dressing .................. E................. ........... ........... ........... ........... ...........
change.
D4999.............. Unspecified periodontal .................. E................. ........... ........... ........... ........... ...........
proc.
D5110.............. Dentures complete .................. E................. ........... ........... ........... ........... ...........
maxillary.
D5120.............. Dentures complete mandible .................. E................. ........... ........... ........... ........... ...........
D5130.............. Dentures immediat .................. E................. ........... ........... ........... ........... ...........
maxillary.
D5140.............. Dentures immediat mandible .................. E................. ........... ........... ........... ........... ...........
D5211.............. Dentures maxill part resin .................. E................. ........... ........... ........... ........... ...........
D5212.............. Dentures mand part resin.. .................. E................. ........... ........... ........... ........... ...........
D5213.............. Dentures maxill part metal .................. E................. ........... ........... ........... ........... ...........
D5214.............. Dentures mandibl part .................. E................. ........... ........... ........... ........... ...........
metal.
D5225.............. Maxillary part denture .................. E................. ........... ........... ........... ........... ...........
flex.
D5226.............. Mandibular part denture .................. E................. ........... ........... ........... ........... ...........
flex.
D5281.............. Removable partial denture. .................. E................. ........... ........... ........... ........... ...........
D5410.............. Dentures adjust cmplt .................. E................. ........... ........... ........... ........... ...........
maxil.
D5411.............. Dentures adjust cmplt mand .................. E................. ........... ........... ........... ........... ...........
D5421.............. Dentures adjust part .................. E................. ........... ........... ........... ........... ...........
maxill.
D5422.............. Dentures adjust part .................. E................. ........... ........... ........... ........... ...........
mandbl.
D5510.............. Dentur repr broken compl .................. E................. ........... ........... ........... ........... ...........
bas.
D5520.............. Replace denture teeth .................. E................. ........... ........... ........... ........... ...........
complt.
D5610.............. Dentures repair resin base .................. E................. ........... ........... ........... ........... ...........
D5620.............. Rep part denture cast .................. E................. ........... ........... ........... ........... ...........
frame.
D5630.............. Rep partial denture clasp. .................. E................. ........... ........... ........... ........... ...........
D5640.............. Replace part denture teeth .................. E................. ........... ........... ........... ........... ...........
D5650.............. Add tooth to partial .................. E................. ........... ........... ........... ........... ...........
denture.
D5660.............. Add clasp to partial .................. E................. ........... ........... ........... ........... ...........
denture.
D5670.............. Replc tth&acrlc on mtl .................. E................. ........... ........... ........... ........... ...........
frmwk.
D5671.............. Replc tth&acrlc mandibular .................. E................. ........... ........... ........... ........... ...........
D5710.............. Dentures rebase cmplt .................. E................. ........... ........... ........... ........... ...........
maxil.
D5711.............. Dentures rebase cmplt mand .................. E................. ........... ........... ........... ........... ...........
D5720.............. Dentures rebase part .................. E................. ........... ........... ........... ........... ...........
maxill.
D5721.............. Dentures rebase part .................. E................. ........... ........... ........... ........... ...........
mandbl.
D5730.............. Denture reln cmplt maxil .................. E................. ........... ........... ........... ........... ...........
ch.
D5731.............. Denture reln cmplt mand .................. E................. ........... ........... ........... ........... ...........
chr.
D5740.............. Denture reln part maxil .................. E................. ........... ........... ........... ........... ...........
chr.
D5741.............. Denture reln part mand chr .................. E................. ........... ........... ........... ........... ...........
D5750.............. Denture reln cmplt max lab .................. E................. ........... ........... ........... ........... ...........
D5751.............. Denture reln cmplt mand .................. E................. ........... ........... ........... ........... ...........
lab.
D5760.............. Denture reln part maxil .................. E................. ........... ........... ........... ........... ...........
lab.
D5761.............. Denture reln part mand lab .................. E................. ........... ........... ........... ........... ...........
D5810.............. Denture interm cmplt .................. E................. ........... ........... ........... ........... ...........
maxill.
D5811.............. Denture interm cmplt .................. E................. ........... ........... ........... ........... ...........
mandbl.
D5820.............. Denture interm part maxill .................. E................. ........... ........... ........... ........... ...........
D5821.............. Denture interm part mandbl .................. E................. ........... ........... ........... ........... ...........
D5850.............. Denture tiss conditn .................. E................. ........... ........... ........... ........... ...........
maxill.
D5851.............. Denture tiss condtin .................. E................. ........... ........... ........... ........... ...........
mandbl.
D5860.............. Overdenture complete...... .................. E................. ........... ........... ........... ........... ...........
D5861.............. Overdenture partial....... .................. E................. ........... ........... ........... ........... ...........
D5862.............. Precision attachment...... .................. E................. ........... ........... ........... ........... ...........
D5867.............. Replacement of precision .................. E................. ........... ........... ........... ........... ...........
att.
D5875.............. Prosthesis modification... .................. E................. ........... ........... ........... ........... ...........
D5899.............. Removable prosthodontic .................. E................. ........... ........... ........... ........... ...........
proc.
D5911.............. Facial moulage sectional.. .................. S................. 0330 9.1677 $583.93 ........... $116.79
D5912.............. Facial moulage complete... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D5913.............. Nasal prosthesis.......... .................. E................. ........... ........... ........... ........... ...........
D5914.............. Auricular prosthesis...... .................. E................. ........... ........... ........... ........... ...........
D5915.............. Orbital prosthesis........ .................. E................. ........... ........... ........... ........... ...........
D5916.............. Ocular prosthesis......... .................. E................. ........... ........... ........... ........... ...........
D5919.............. Facial prosthesis......... .................. E................. ........... ........... ........... ........... ...........
D5922.............. Nasal septal prosthesis... .................. E................. ........... ........... ........... ........... ...........
D5923.............. Ocular prosthesis interim. .................. E................. ........... ........... ........... ........... ...........
D5924.............. Cranial prosthesis........ .................. E................. ........... ........... ........... ........... ...........
D5925.............. Facial augmentation .................. E................. ........... ........... ........... ........... ...........
implant.
D5926.............. Replacement nasal .................. E................. ........... ........... ........... ........... ...........
prosthesis.
D5927.............. Auricular replacement..... .................. E................. ........... ........... ........... ........... ...........
D5928.............. Orbital replacement....... .................. E................. ........... ........... ........... ........... ...........
D5929.............. Facial replacement........ .................. E................. ........... ........... ........... ........... ...........
D5931.............. Surgical obturator........ .................. E................. ........... ........... ........... ........... ...........
D5932.............. Postsurgical obturator.... .................. E................. ........... ........... ........... ........... ...........
D5933.............. Refitting of obturator.... .................. E................. ........... ........... ........... ........... ...........
D5934.............. Mandibular flange .................. E................. ........... ........... ........... ........... ...........
prosthesis.
D5935.............. Mandibular denture prosth. .................. E................. ........... ........... ........... ........... ...........
D5936.............. Temp obturator prosthesis. .................. E................. ........... ........... ........... ........... ...........
D5937.............. Trismus appliance......... .................. E................. ........... ........... ........... ........... ...........
D5951.............. Feeding aid............... .................. E................. ........... ........... ........... ........... ...........
D5952.............. Pediatric speech aid...... .................. E................. ........... ........... ........... ........... ...........
D5953.............. Adult speech aid.......... .................. E................. ........... ........... ........... ........... ...........
D5954.............. Superimposed prosthesis... .................. E................. ........... ........... ........... ........... ...........
D5955.............. Palatal lift prosthesis... .................. E................. ........... ........... ........... ........... ...........
D5958.............. Intraoral con def inter .................. E................. ........... ........... ........... ........... ...........
plt.
D5959.............. Intraoral con def mod .................. E................. ........... ........... ........... ........... ...........
palat.
[[Page 67122]]
D5960.............. Modify speech aid .................. E................. ........... ........... ........... ........... ...........
prosthesis.
D5982.............. Surgical stent............ .................. E................. ........... ........... ........... ........... ...........
D5983.............. Radiation applicator...... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D5984.............. Radiation shield.......... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D5985.............. Radiation cone locator.... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D5986.............. Fluoride applicator....... .................. E................. ........... ........... ........... ........... ...........
D5987.............. Commissure splint......... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D5988.............. Surgical splint........... .................. E................. ........... ........... ........... ........... ...........
D5999.............. Maxillofacial prosthesis.. .................. E................. ........... ........... ........... ........... ...........
D6010.............. Odontics endosteal implant .................. E................. ........... ........... ........... ........... ...........
D6012.............. Endosteal implant......... .................. E................. ........... ........... ........... ........... ...........
D6040.............. Odontics eposteal implant. .................. E................. ........... ........... ........... ........... ...........
D6050.............. Odontics transosteal .................. E................. ........... ........... ........... ........... ...........
implnt.
D6053.............. Implnt/abtmnt spprt remv .................. E................. ........... ........... ........... ........... ...........
dnt.
D6054.............. Implnt/abtmnt spprt .................. E................. ........... ........... ........... ........... ...........
remvprtl.
D6055.............. Implant connecting bar.... .................. E................. ........... ........... ........... ........... ...........
D6056.............. Prefabricated abutment.... .................. E................. ........... ........... ........... ........... ...........
D6057.............. Custom abutment........... .................. E................. ........... ........... ........... ........... ...........
D6058.............. Abutment supported crown.. .................. E................. ........... ........... ........... ........... ...........
D6059.............. Abutment supported mtl .................. E................. ........... ........... ........... ........... ...........
crown.
D6060.............. Abutment supported mtl .................. E................. ........... ........... ........... ........... ...........
crown.
D6061.............. Abutment supported mtl .................. E................. ........... ........... ........... ........... ...........
crown.
D6062.............. Abutment supported mtl .................. E................. ........... ........... ........... ........... ...........
crown.
D6063.............. Abutment supported mtl .................. E................. ........... ........... ........... ........... ...........
crown.
D6064.............. Abutment supported mtl .................. E................. ........... ........... ........... ........... ...........
crown.
D6065.............. Implant supported crown... .................. E................. ........... ........... ........... ........... ...........
D6066.............. Implant supported mtl .................. E................. ........... ........... ........... ........... ...........
crown.
D6067.............. Implant supported mtl .................. E................. ........... ........... ........... ........... ...........
crown.
D6068.............. Abutment supported .................. E................. ........... ........... ........... ........... ...........
retainer.
D6069.............. Abutment supported .................. E................. ........... ........... ........... ........... ...........
retainer.
D6070.............. Abutment supported .................. E................. ........... ........... ........... ........... ...........
retainer.
D6071.............. Abutment supported .................. E................. ........... ........... ........... ........... ...........
retainer.
D6072.............. Abutment supported .................. E................. ........... ........... ........... ........... ...........
retainer.
D6073.............. Abutment supported .................. E................. ........... ........... ........... ........... ...........
retainer.
D6074.............. Abutment supported .................. E................. ........... ........... ........... ........... ...........
retainer.
D6075.............. Implant supported retainer .................. E................. ........... ........... ........... ........... ...........
D6076.............. Implant supported retainer .................. E................. ........... ........... ........... ........... ...........
D6077.............. Implant supported retainer .................. E................. ........... ........... ........... ........... ...........
D6078.............. Implnt/abut suprtd fixd .................. E................. ........... ........... ........... ........... ...........
dent.
D6079.............. Implnt/abut suprtd fixd .................. E................. ........... ........... ........... ........... ...........
dent.
D6080.............. Implant maintenance....... .................. E................. ........... ........... ........... ........... ...........
D6090.............. Repair implant............ .................. E................. ........... ........... ........... ........... ...........
D6091.............. Repl semi/precision attach .................. E................. ........... ........... ........... ........... ...........
D6092.............. Recement supp crown....... .................. E................. ........... ........... ........... ........... ...........
D6093.............. Recement supp part denture .................. E................. ........... ........... ........... ........... ...........
D6094.............. Abut support crown .................. E................. ........... ........... ........... ........... ...........
titanium.
D6095.............. Odontics repr abutment.... .................. E................. ........... ........... ........... ........... ...........
D6100.............. Removal of implant........ .................. E................. ........... ........... ........... ........... ...........
D6190.............. Radio/surgical implant .................. E................. ........... ........... ........... ........... ...........
index.
D6194.............. Abut support retainer .................. E................. ........... ........... ........... ........... ...........
titani.
D6199.............. Implant procedure......... .................. E................. ........... ........... ........... ........... ...........
D6205.............. Pontic-indirect resin .................. E................. ........... ........... ........... ........... ...........
based.
D6210.............. Prosthodont high noble .................. E................. ........... ........... ........... ........... ...........
metal.
D6211.............. Bridge base metal cast.... .................. E................. ........... ........... ........... ........... ...........
D6212.............. Bridge noble metal cast... .................. E................. ........... ........... ........... ........... ...........
D6214.............. Pontic titanium........... .................. E................. ........... ........... ........... ........... ...........
D6240.............. Bridge porcelain high .................. E................. ........... ........... ........... ........... ...........
noble.
D6241.............. Bridge porcelain base .................. E................. ........... ........... ........... ........... ...........
metal.
D6242.............. Bridge porcelain nobel .................. E................. ........... ........... ........... ........... ...........
metal.
D6245.............. Bridge porcelain/ceramic.. .................. E................. ........... ........... ........... ........... ...........
D6250.............. Bridge resin w/high noble. .................. E................. ........... ........... ........... ........... ...........
D6251.............. Bridge resin base metal... .................. E................. ........... ........... ........... ........... ...........
D6252.............. Bridge resin w/noble metal .................. E................. ........... ........... ........... ........... ...........
D6253.............. Provisional pontic........ .................. E................. ........... ........... ........... ........... ...........
D6545.............. Dental retainr cast metl.. .................. E................. ........... ........... ........... ........... ...........
D6548.............. Porcelain/ceramic retainer .................. E................. ........... ........... ........... ........... ...........
D6600.............. Porcelain/ceramic inlay .................. E................. ........... ........... ........... ........... ...........
2srf.
D6601.............. Porc/ceram inlay >= 3 .................. E................. ........... ........... ........... ........... ...........
surfac.
D6602.............. Cst hgh nble mtl inlay 2 .................. E................. ........... ........... ........... ........... ...........
srf.
D6603.............. Cst hgh nble mtl inlay .................. E................. ........... ........... ........... ........... ...........
>=3sr.
D6604.............. Cst bse mtl inlay 2 .................. E................. ........... ........... ........... ........... ...........
surfaces.
D6605.............. Cst bse mtl inlay >= 3 .................. E................. ........... ........... ........... ........... ...........
surfa.
D6606.............. Cast noble metal inlay 2 .................. E................. ........... ........... ........... ........... ...........
sur.
D6607.............. Cst noble mtl inlay >=3 .................. E................. ........... ........... ........... ........... ...........
surf.
D6608.............. Onlay porc/crmc 2 surfaces .................. E................. ........... ........... ........... ........... ...........
D6609.............. Onlay porc/crmc >=3 .................. E................. ........... ........... ........... ........... ...........
surfaces.
D6610.............. Onlay cst hgh nbl mtl 2 .................. E................. ........... ........... ........... ........... ...........
srfc.
D6611.............. Onlay cst hgh nbl mtl .................. E................. ........... ........... ........... ........... ...........
>=3srf.
D6612.............. Onlay cst base mtl 2 .................. E................. ........... ........... ........... ........... ...........
surface.
D6613.............. Onlay cst base mtl >=3 .................. E................. ........... ........... ........... ........... ...........
surfa.
[[Page 67123]]
D6614.............. Onlay cst nbl mtl 2 .................. E................. ........... ........... ........... ........... ...........
surfaces.
D6615.............. Onlay cst nbl mtl >=3 .................. E................. ........... ........... ........... ........... ...........
surfac.
D6624.............. Inlay titanium............ .................. E................. ........... ........... ........... ........... ...........
D6634.............. Onlay titanium............ .................. E................. ........... ........... ........... ........... ...........
D6710.............. Crown-indirect resin based .................. E................. ........... ........... ........... ........... ...........
D6720.............. Retain crown resin w hi .................. E................. ........... ........... ........... ........... ...........
nble.
D6721.............. Crown resin w/base metal.. .................. E................. ........... ........... ........... ........... ...........
D6722.............. Crown resin w/noble metal. .................. E................. ........... ........... ........... ........... ...........
D6740.............. Crown porcelain/ceramic... .................. E................. ........... ........... ........... ........... ...........
D6750.............. Crown porcelain high noble .................. E................. ........... ........... ........... ........... ...........
D6751.............. Crown porcelain base metal .................. E................. ........... ........... ........... ........... ...........
D6752.............. Crown porcelain noble .................. E................. ........... ........... ........... ........... ...........
metal.
D6780.............. Crown 3/4 high noble metal .................. E................. ........... ........... ........... ........... ...........
D6781.............. Crown 3/4 cast based metal .................. E................. ........... ........... ........... ........... ...........
D6782.............. Crown 3/4 cast noble metal .................. E................. ........... ........... ........... ........... ...........
D6783.............. Crown 3/4 porcelain/ .................. E................. ........... ........... ........... ........... ...........
ceramic.
D6790.............. Crown full high noble .................. E................. ........... ........... ........... ........... ...........
metal.
D6791.............. Crown full base metal cast .................. E................. ........... ........... ........... ........... ...........
D6792.............. Crown full noble metal .................. E................. ........... ........... ........... ........... ...........
cast.
D6793.............. Provisional retainer crown .................. E................. ........... ........... ........... ........... ...........
D6794.............. Crown titanium............ .................. E................. ........... ........... ........... ........... ...........
D6920.............. Dental connector bar...... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D6930.............. Dental recement bridge.... .................. E................. ........... ........... ........... ........... ...........
D6940.............. Stress breaker............ .................. E................. ........... ........... ........... ........... ...........
D6950.............. Precision attachment...... .................. E................. ........... ........... ........... ........... ...........
D6970.............. Post & core plus retainer. .................. E................. ........... ........... ........... ........... ...........
D6972.............. Prefab post & core plus .................. E................. ........... ........... ........... ........... ...........
reta.
D6973.............. Core build up for retainer .................. E................. ........... ........... ........... ........... ...........
D6975.............. Coping metal.............. .................. E................. ........... ........... ........... ........... ...........
D6976.............. Each addtnl cast post..... .................. E................. ........... ........... ........... ........... ...........
D6977.............. Each addtl prefab post.... .................. E................. ........... ........... ........... ........... ...........
D6980.............. Bridge repair............. .................. E................. ........... ........... ........... ........... ...........
D6985.............. Pediatric partial denture .................. E................. ........... ........... ........... ........... ...........
fx.
D6999.............. Fixed prosthodontic proc.. .................. E................. ........... ........... ........... ........... ...........
D7111.............. Extraction coronal .................. S................. 0330 9.1677 $583.93 ........... $116.79
remnants.
D7140.............. Extraction erupted tooth/ .................. S................. 0330 9.1677 $583.93 ........... $116.79
exr.
D7210.............. Rem imp tooth w mucoper .................. S................. 0330 9.1677 $583.93 ........... $116.79
flp.
D7220.............. Impact tooth remov soft .................. S................. 0330 9.1677 $583.93 ........... $116.79
tiss.
D7230.............. Impact tooth remov part .................. S................. 0330 9.1677 $583.93 ........... $116.79
bony.
D7240.............. Impact tooth remov comp .................. S................. 0330 9.1677 $583.93 ........... $116.79
bony.
D7241.............. Impact tooth rem bony w/ .................. S................. 0330 9.1677 $583.93 ........... $116.79
comp.
D7250.............. Tooth root removal........ .................. S................. 0330 9.1677 $583.93 ........... $116.79
D7260.............. Oral antral fistula .................. S................. 0330 9.1677 $583.93 ........... $116.79
closure.
D7261.............. Primary closure sinus perf .................. S................. 0330 9.1677 $583.93 ........... $116.79
D7270.............. Tooth reimplantation...... .................. E................. ........... ........... ........... ........... ...........
D7272.............. Tooth transplantation..... .................. E................. ........... ........... ........... ........... ...........
D7280.............. Exposure impact tooth .................. E................. ........... ........... ........... ........... ...........
orthod.
D7282.............. Mobilize erupted/malpos .................. E................. ........... ........... ........... ........... ...........
toot.
D7283.............. Place device impacted .................. B................. ........... ........... ........... ........... ...........
tooth.
D7285.............. Biopsy of oral tissue hard .................. E................. ........... ........... ........... ........... ...........
D7286.............. Biopsy of oral tissue soft .................. E................. ........... ........... ........... ........... ...........
D7287.............. Exfoliative cytolog .................. E................. ........... ........... ........... ........... ...........
collect.
D7288.............. Brush biopsy.............. .................. B................. ........... ........... ........... ........... ...........
D7290.............. Repositioning of teeth.... .................. E................. ........... ........... ........... ........... ...........
D7291.............. Transseptal fiberotomy.... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D7292.............. Screw retained plate...... .................. E................. ........... ........... ........... ........... ...........
D7293.............. Temp anchorage dev w flap. .................. E................. ........... ........... ........... ........... ...........
D7294.............. Temp anchorage dev w/o .................. E................. ........... ........... ........... ........... ...........
flap.
D7310.............. Alveoplasty w/ extraction. .................. E................. ........... ........... ........... ........... ...........
D7311.............. Alveoloplasty w/extract 1- .................. E................. ........... ........... ........... ........... ...........
3.
D7320.............. Alveoplasty w/o extraction .................. E................. ........... ........... ........... ........... ...........
D7321.............. Alveoloplasty not w/ .................. B................. ........... ........... ........... ........... ...........
extracts.
D7340.............. Vestibuloplasty ridge .................. E................. ........... ........... ........... ........... ...........
extens.
D7350.............. Vestibuloplasty exten .................. E................. ........... ........... ........... ........... ...........
graft.
D7410.............. Rad exc lesion up to 1.25 .................. E................. ........... ........... ........... ........... ...........
cm.
D7411.............. Excision benign .................. E................. ........... ........... ........... ........... ...........
lesion>1.25c.
D7412.............. Excision benign lesion .................. E................. ........... ........... ........... ........... ...........
compl.
D7413.............. Excision malig .................. E................. ........... ........... ........... ........... ...........
lesion<=1.25c.
D7414.............. Excision malig .................. E................. ........... ........... ........... ........... ...........
lesion>1.25cm.
D7415.............. Excision malig les .................. E................. ........... ........... ........... ........... ...........
complicat.
D7440.............. Malig tumor exc to 1.25 cm .................. E................. ........... ........... ........... ........... ...........
D7441.............. Malig tumor > 1.25 cm..... .................. E................. ........... ........... ........... ........... ...........
D7450.............. Rem odontogen cyst to .................. E................. ........... ........... ........... ........... ...........
1.25cm.
D7451.............. Rem odontogen cyst > 1.25 .................. E................. ........... ........... ........... ........... ...........
cm.
D7460.............. Rem nonodonto cyst to .................. E................. ........... ........... ........... ........... ...........
1.25cm.
D7461.............. Rem nonodonto cyst > 1.25 .................. E................. ........... ........... ........... ........... ...........
cm.
D7465.............. Lesion destruction........ .................. E................. ........... ........... ........... ........... ...........
D7471.............. Rem exostosis any site.... .................. E................. ........... ........... ........... ........... ...........
D7472.............. Removal of torus palatinus .................. E................. ........... ........... ........... ........... ...........
D7473.............. Remove torus mandibularis. .................. E................. ........... ........... ........... ........... ...........
[[Page 67124]]
D7485.............. Surg reduct .................. E................. ........... ........... ........... ........... ...........
osseoustuberosit.
D7490.............. Maxilla or mandible .................. E................. ........... ........... ........... ........... ...........
resectio.
D7510.............. I&d absc intraoral soft .................. E................. ........... ........... ........... ........... ...........
tiss.
D7511.............. Incision/drain abscess .................. B................. ........... ........... ........... ........... ...........
intra.
D7520.............. I&d abscess extraoral..... .................. E................. ........... ........... ........... ........... ...........
D7521.............. Incision/drain abscess .................. B................. ........... ........... ........... ........... ...........
extra.
D7530.............. Removal fb skin/areolar .................. E................. ........... ........... ........... ........... ...........
tiss.
D7540.............. Removal of fb reaction.... .................. E................. ........... ........... ........... ........... ...........
D7550.............. Removal of sloughed off .................. E................. ........... ........... ........... ........... ...........
bone.
D7560.............. Maxillary sinusotomy...... .................. E................. ........... ........... ........... ........... ...........
D7610.............. Maxilla open reduct simple .................. E................. ........... ........... ........... ........... ...........
D7620.............. Clsd reduct simpl maxilla .................. E................. ........... ........... ........... ........... ...........
fx.
D7630.............. Open red simpl mandible fx .................. E................. ........... ........... ........... ........... ...........
D7640.............. Clsd red simpl mandible fx .................. E................. ........... ........... ........... ........... ...........
D7650.............. Open red simp malar/zygom .................. E................. ........... ........... ........... ........... ...........
fx.
D7660.............. Clsd red simp malar/zygom .................. E................. ........... ........... ........... ........... ...........
fx.
D7670.............. Closd rductn splint .................. E................. ........... ........... ........... ........... ...........
alveolus.
D7671.............. Alveolus open reduction... .................. E................. ........... ........... ........... ........... ...........
D7680.............. Reduct simple facial bone .................. E................. ........... ........... ........... ........... ...........
fx.
D7710.............. Maxilla open reduct .................. E................. ........... ........... ........... ........... ...........
compound.
D7720.............. Clsd reduct compd maxilla .................. E................. ........... ........... ........... ........... ...........
fx.
D7730.............. Open reduct compd mandble .................. E................. ........... ........... ........... ........... ...........
fx.
D7740.............. Clsd reduct compd mandble .................. E................. ........... ........... ........... ........... ...........
fx.
D7750.............. Open red comp malar/zygma .................. E................. ........... ........... ........... ........... ...........
fx.
D7760.............. Clsd red comp malar/zygma .................. E................. ........... ........... ........... ........... ...........
fx.
D7770.............. Open reduc compd alveolus .................. E................. ........... ........... ........... ........... ...........
fx.
D7771.............. Alveolus clsd reduc stblz .................. E................. ........... ........... ........... ........... ...........
te.
D7780.............. Reduct compnd facial bone .................. E................. ........... ........... ........... ........... ...........
fx.
D7810.............. Tmj open reduct- .................. E................. ........... ........... ........... ........... ...........
dislocation.
D7820.............. Closed tmp manipulation... .................. E................. ........... ........... ........... ........... ...........
D7830.............. Tmj manipulation under .................. E................. ........... ........... ........... ........... ...........
anest.
D7840.............. Removal of tmj condyle.... .................. E................. ........... ........... ........... ........... ...........
D7850.............. Tmj meniscectomy.......... .................. E................. ........... ........... ........... ........... ...........
D7852.............. Tmj repair of joint disc.. .................. E................. ........... ........... ........... ........... ...........
D7854.............. Tmj excisn of joint .................. E................. ........... ........... ........... ........... ...........
membrane.
D7856.............. Tmj cutting of a muscle... .................. E................. ........... ........... ........... ........... ...........
D7858.............. Tmj reconstruction........ .................. E................. ........... ........... ........... ........... ...........
D7860.............. Tmj cutting into joint.... .................. E................. ........... ........... ........... ........... ...........
D7865.............. Tmj reshaping components.. .................. E................. ........... ........... ........... ........... ...........
D7870.............. Tmj aspiration joint fluid .................. E................. ........... ........... ........... ........... ...........
D7871.............. Lysis + lavage w catheters .................. E................. ........... ........... ........... ........... ...........
D7872.............. Tmj diagnostic arthroscopy .................. E................. ........... ........... ........... ........... ...........
D7873.............. Tmj arthroscopy lysis .................. E................. ........... ........... ........... ........... ...........
adhesn.
D7874.............. Tmj arthroscopy disc .................. E................. ........... ........... ........... ........... ...........
reposit.
D7875.............. Tmj arthroscopy .................. E................. ........... ........... ........... ........... ...........
synovectomy.
D7876.............. Tmj arthroscopy discectomy .................. E................. ........... ........... ........... ........... ...........
D7877.............. Tmj arthroscopy .................. E................. ........... ........... ........... ........... ...........
debridement.
D7880.............. Occlusal orthotic .................. E................. ........... ........... ........... ........... ...........
appliance.
D7899.............. Tmj unspecified therapy... .................. E................. ........... ........... ........... ........... ...........
D7910.............. Dent sutur recent wnd to .................. E................. ........... ........... ........... ........... ...........
5cm.
D7911.............. Dental suture wound to 5 .................. E................. ........... ........... ........... ........... ...........
cm.
D7912.............. Suture complicate wnd > 5 .................. E................. ........... ........... ........... ........... ...........
cm.
D7920.............. Dental skin graft......... .................. E................. ........... ........... ........... ........... ...........
D7940.............. Reshaping bone .................. S................. 0330 9.1677 $583.93 ........... $116.79
orthognathic.
D7941.............. Bone cutting ramus closed. .................. E................. ........... ........... ........... ........... ...........
D7943.............. Cutting ramus open w/graft .................. E................. ........... ........... ........... ........... ...........
D7944.............. Bone cutting segmented.... .................. E................. ........... ........... ........... ........... ...........
D7945.............. Bone cutting body mandible .................. E................. ........... ........... ........... ........... ...........
D7946.............. Reconstruction maxilla .................. E................. ........... ........... ........... ........... ...........
total.
D7947.............. Reconstruct maxilla .................. E................. ........... ........... ........... ........... ...........
segment.
D7948.............. Reconstruct midface no .................. E................. ........... ........... ........... ........... ...........
graft.
D7949.............. Reconstruct midface w/ .................. E................. ........... ........... ........... ........... ...........
graft.
D7950.............. Mandible graft............ .................. E................. ........... ........... ........... ........... ...........
D7951.............. Sinus aug w bone/bone sup. .................. E................. ........... ........... ........... ........... ...........
D7953.............. Bone replacement graft.... .................. E................. ........... ........... ........... ........... ...........
D7955.............. Repair maxillofacial .................. E................. ........... ........... ........... ........... ...........
defects.
D7960.............. Frenulectomy/frenulotomy.. .................. E................. ........... ........... ........... ........... ...........
D7963.............. Frenuloplasty............. .................. E................. ........... ........... ........... ........... ...........
D7970.............. Excision hyperplastic .................. E................. ........... ........... ........... ........... ...........
tissue.
D7971.............. Excision pericoronal .................. E................. ........... ........... ........... ........... ...........
gingiva.
D7972.............. Surg redct fibrous .................. E................. ........... ........... ........... ........... ...........
tuberosit.
D7980.............. Sialolithotomy............ .................. E................. ........... ........... ........... ........... ...........
D7981.............. Excision of salivary gland .................. E................. ........... ........... ........... ........... ...........
D7982.............. Sialodochoplasty.......... .................. E................. ........... ........... ........... ........... ...........
D7983.............. Closure of salivary .................. E................. ........... ........... ........... ........... ...........
fistula.
D7990.............. Emergency tracheotomy..... .................. E................. ........... ........... ........... ........... ...........
D7991.............. Dental coronoidectomy..... .................. E................. ........... ........... ........... ........... ...........
D7995.............. Synthetic graft facial .................. E................. ........... ........... ........... ........... ...........
bones.
D7996.............. Implant mandible for .................. E................. ........... ........... ........... ........... ...........
augment.
D7997.............. Appliance removal......... .................. E................. ........... ........... ........... ........... ...........
[[Page 67125]]
D7998.............. Intraoral place of fix dev .................. E................. ........... ........... ........... ........... ...........
D7999.............. Oral surgery procedure.... .................. E................. ........... ........... ........... ........... ...........
D8010.............. Limited dental tx primary. .................. E................. ........... ........... ........... ........... ...........
D8020.............. Limited dental tx .................. E................. ........... ........... ........... ........... ...........
transition.
D8030.............. Limited dental tx .................. E................. ........... ........... ........... ........... ...........
adolescent.
D8040.............. Limited dental tx adult... .................. E................. ........... ........... ........... ........... ...........
D8050.............. Intercep dental tx primary .................. E................. ........... ........... ........... ........... ...........
D8060.............. Intercep dental tx .................. E................. ........... ........... ........... ........... ...........
transitn.
D8070.............. Compre dental tx .................. E................. ........... ........... ........... ........... ...........
transition.
D8080.............. Compre dental tx .................. E................. ........... ........... ........... ........... ...........
adolescent.
D8090.............. Compre dental tx adult.... .................. E................. ........... ........... ........... ........... ...........
D8210.............. Orthodontic rem appliance .................. E................. ........... ........... ........... ........... ...........
tx.
D8220.............. Fixed appliance therapy .................. E................. ........... ........... ........... ........... ...........
habt.
D8660.............. Preorthodontic tx visit... .................. E................. ........... ........... ........... ........... ...........
D8670.............. Periodic orthodontc tx .................. E................. ........... ........... ........... ........... ...........
visit.
D8680.............. Orthodontic retention..... .................. E................. ........... ........... ........... ........... ...........
D8690.............. Orthodontic treatment..... .................. E................. ........... ........... ........... ........... ...........
D8691.............. Repair ortho appliance.... .................. E................. ........... ........... ........... ........... ...........
D8692.............. Replacement retainer...... .................. E................. ........... ........... ........... ........... ...........
D8693.............. Rebond/cement/repair .................. E................. ........... ........... ........... ........... ...........
retain.
D8999.............. Orthodontic procedure..... .................. E................. ........... ........... ........... ........... ...........
D9110.............. Tx dental pain minor proc. .................. N................. ........... ........... ........... ........... ...........
D9120.............. Fix partial denture .................. E................. ........... ........... ........... ........... ...........
section.
D9210.............. Dent anesthesia w/o .................. E................. ........... ........... ........... ........... ...........
surgery.
D9211.............. Regional block anesthesia. .................. E................. ........... ........... ........... ........... ...........
D9212.............. Trigeminal block .................. E................. ........... ........... ........... ........... ...........
anesthesia.
D9215.............. Local anesthesia.......... .................. E................. ........... ........... ........... ........... ...........
D9220.............. General anesthesia........ .................. E................. ........... ........... ........... ........... ...........
D9221.............. General anesthesia ea ad .................. E................. ........... ........... ........... ........... ...........
15m.
D9230.............. Analgesia................. .................. N................. ........... ........... ........... ........... ...........
D9241.............. Intravenous sedation...... .................. E................. ........... ........... ........... ........... ...........
D9242.............. IV sedation ea ad 30 m.... .................. E................. ........... ........... ........... ........... ...........
D9248.............. Sedation (non-iv)......... .................. N................. ........... ........... ........... ........... ...........
D9310.............. Dental consultation....... .................. E................. ........... ........... ........... ........... ...........
D9410.............. Dental house call......... .................. E................. ........... ........... ........... ........... ...........
D9420.............. Hospital call............. .................. E................. ........... ........... ........... ........... ...........
D9430.............. Office visit during hours. .................. E................. ........... ........... ........... ........... ...........
D9440.............. Office visit after hours.. .................. E................. ........... ........... ........... ........... ...........
D9450.............. Case presentation tx plan. .................. E................. ........... ........... ........... ........... ...........
D9610.............. Dent therapeutic drug .................. E................. ........... ........... ........... ........... ...........
inject.
D9612.............. Thera par drugs 2 or > .................. E................. ........... ........... ........... ........... ...........
admin.
D9630.............. Other drugs/medicaments... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D9910.............. Dent appl desensitizing .................. E................. ........... ........... ........... ........... ...........
med.
D9911.............. Appl desensitizing resin.. .................. E................. ........... ........... ........... ........... ...........
D9920.............. Behavior management....... .................. E................. ........... ........... ........... ........... ...........
D9930.............. Treatment of complications .................. S................. 0330 9.1677 $583.93 ........... $116.79
D9940.............. Dental occlusal guard..... .................. S................. 0330 9.1677 $583.93 ........... $116.79
D9941.............. Fabrication athletic guard .................. E................. ........... ........... ........... ........... ...........
D9942.............. Repair/reline occlusal .................. E................. ........... ........... ........... ........... ...........
guard.
D9950.............. Occlusion analysis........ .................. S................. 0330 9.1677 $583.93 ........... $116.79
D9951.............. Limited occlusal .................. S................. 0330 9.1677 $583.93 ........... $116.79
adjustment.
D9952.............. Complete occlusal .................. S................. 0330 9.1677 $583.93 ........... $116.79
adjustment.
D9970.............. Enamel microabrasion...... .................. E................. ........... ........... ........... ........... ...........
D9971.............. Odontoplasty 1-2 teeth.... .................. E................. ........... ........... ........... ........... ...........
D9972.............. Extrnl bleaching per arch. .................. E................. ........... ........... ........... ........... ...........
D9973.............. Extrnl bleaching per tooth .................. E................. ........... ........... ........... ........... ...........
D9974.............. Intrnl bleaching per tooth .................. E................. ........... ........... ........... ........... ...........
D9999.............. Adjunctive procedure...... .................. E................. ........... ........... ........... ........... ...........
E0100.............. Cane adjust/fixed with tip .................. Y................. ........... ........... ........... ........... ...........
E0105.............. Cane adjust/fixed quad/3 .................. Y................. ........... ........... ........... ........... ...........
pro.
E0110.............. Crutch forearm pair....... .................. Y................. ........... ........... ........... ........... ...........
E0111.............. Crutch forearm each....... .................. Y................. ........... ........... ........... ........... ...........
E0112.............. Crutch underarm pair wood. .................. Y................. ........... ........... ........... ........... ...........
E0113.............. Crutch underarm each wood. .................. Y................. ........... ........... ........... ........... ...........
E0114.............. Crutch underarm pair no .................. Y................. ........... ........... ........... ........... ...........
wood.
E0116.............. Crutch underarm each no .................. Y................. ........... ........... ........... ........... ...........
wood.
E0117.............. Underarm springassist .................. Y................. ........... ........... ........... ........... ...........
crutch.
E0118.............. Crutch substitute......... .................. E................. ........... ........... ........... ........... ...........
E0130.............. Walker rigid adjust/fixed .................. Y................. ........... ........... ........... ........... ...........
ht.
E0135.............. Walker folding adjust/ .................. Y................. ........... ........... ........... ........... ...........
fixed.
E0140.............. Walker w trunk support.... .................. Y................. ........... ........... ........... ........... ...........
E0141.............. Rigid wheeled walker adj/ .................. Y................. ........... ........... ........... ........... ...........
fix.
E0143.............. Walker folding wheeled w/o .................. Y................. ........... ........... ........... ........... ...........
s.
E0144.............. Enclosed walker w rear .................. Y................. ........... ........... ........... ........... ...........
seat.
E0147.............. Walker variable wheel .................. Y................. ........... ........... ........... ........... ...........
resist.
E0148.............. Heavyduty walker no wheels .................. Y................. ........... ........... ........... ........... ...........
E0149.............. Heavy duty wheeled walker. .................. Y................. ........... ........... ........... ........... ...........
E0153.............. Forearm crutch platform .................. Y................. ........... ........... ........... ........... ...........
atta.
E0154.............. Walker platform attachment .................. Y................. ........... ........... ........... ........... ...........
E0155.............. Walker wheel .................. Y................. ........... ........... ........... ........... ...........
attachment,pair.
[[Page 67126]]
E0156.............. Walker seat attachment.... .................. Y................. ........... ........... ........... ........... ...........
E0157.............. Walker crutch attachment.. .................. Y................. ........... ........... ........... ........... ...........
E0158.............. Walker leg extenders set .................. Y................. ........... ........... ........... ........... ...........
of4.
E0159.............. Brake for wheeled walker.. .................. Y................. ........... ........... ........... ........... ...........
E0160.............. Sitz type bath or .................. Y................. ........... ........... ........... ........... ...........
equipment.
E0161.............. Sitz bath/equipment w/ .................. Y................. ........... ........... ........... ........... ...........
faucet.
E0162.............. Sitz bath chair........... .................. Y................. ........... ........... ........... ........... ...........
E0163.............. Commode chair with fixed .................. Y................. ........... ........... ........... ........... ...........
arm.
E0165.............. Commode chair with .................. Y................. ........... ........... ........... ........... ...........
detacharm.
E0167.............. Commode chair pail or pan. .................. Y................. ........... ........... ........... ........... ...........
E0168.............. Heavyduty/wide commode .................. Y................. ........... ........... ........... ........... ...........
chair.
E0170.............. Commode chair electric.... .................. Y................. ........... ........... ........... ........... ...........
E0171.............. Commode chair non-electric .................. Y................. ........... ........... ........... ........... ...........
E0172.............. Seat lift mechanism toilet .................. E................. ........... ........... ........... ........... ...........
E0175.............. Commode chair foot rest... .................. Y................. ........... ........... ........... ........... ...........
E0181.............. Press pad alternating w/ .................. Y................. ........... ........... ........... ........... ...........
pum.
E0182.............. Replace pump, alt press .................. Y................. ........... ........... ........... ........... ...........
pad.
E0184.............. Dry pressure mattress..... .................. Y................. ........... ........... ........... ........... ...........
E0185.............. Gel pressure mattress pad. .................. Y................. ........... ........... ........... ........... ...........
E0186.............. Air pressure mattress..... .................. Y................. ........... ........... ........... ........... ...........
E0187.............. Water pressure mattress... .................. Y................. ........... ........... ........... ........... ...........
E0188.............. Synthetic sheepskin pad... .................. Y................. ........... ........... ........... ........... ...........
E0189.............. Lambswool sheepskin pad... .................. Y................. ........... ........... ........... ........... ...........
E0190.............. Positioning cushion....... .................. E................. ........... ........... ........... ........... ...........
E0191.............. Protector heel or elbow... .................. Y................. ........... ........... ........... ........... ...........
E0193.............. Powered air flotation bed. .................. Y................. ........... ........... ........... ........... ...........
E0194.............. Air fluidized bed......... .................. Y................. ........... ........... ........... ........... ...........
E0196.............. Gel pressure mattress..... .................. Y................. ........... ........... ........... ........... ...........
E0197.............. Air pressure pad for .................. Y................. ........... ........... ........... ........... ...........
mattres.
E0198.............. Water pressure pad for .................. Y................. ........... ........... ........... ........... ...........
mattr.
E0199.............. Dry pressure pad for .................. Y................. ........... ........... ........... ........... ...........
mattres.
E0200.............. Heat lamp without stand... .................. Y................. ........... ........... ........... ........... ...........
E0202.............. Phototherapy light w/ .................. Y................. ........... ........... ........... ........... ...........
photom.
E0203.............. Therapeutic lightbox CH................ E................. ........... ........... ........... ........... ...........
tabletp.
E0205.............. Heat lamp with stand...... .................. Y................. ........... ........... ........... ........... ...........
E0210.............. Electric heat pad standard .................. Y................. ........... ........... ........... ........... ...........
E0215.............. Electric heat pad moist... .................. Y................. ........... ........... ........... ........... ...........
E0217.............. Water circ heat pad w pump .................. Y................. ........... ........... ........... ........... ...........
E0218.............. Water circ cold pad w pump .................. Y................. ........... ........... ........... ........... ...........
E0220.............. Hot water bottle.......... .................. Y................. ........... ........... ........... ........... ...........
E0221.............. Infrared heating pad .................. Y................. ........... ........... ........... ........... ...........
system.
E0225.............. Hydrocollator unit........ .................. Y................. ........... ........... ........... ........... ...........
E0230.............. Ice cap or collar......... .................. Y................. ........... ........... ........... ........... ...........
E0231.............. Wound warming device...... .................. E................. ........... ........... ........... ........... ...........
E0232.............. Warming card for NWT...... .................. E................. ........... ........... ........... ........... ...........
E0235.............. Paraffin bath unit .................. Y................. ........... ........... ........... ........... ...........
portable.
E0236.............. Pump for water circulating .................. Y................. ........... ........... ........... ........... ...........
p.
E0238.............. Heat pad non-electric .................. Y................. ........... ........... ........... ........... ...........
moist.
E0239.............. Hydrocollator unit .................. Y................. ........... ........... ........... ........... ...........
portable.
E0240.............. Bath/shower chair......... .................. E................. ........... ........... ........... ........... ...........
E0241.............. Bath tub wall rail........ .................. E................. ........... ........... ........... ........... ...........
E0242.............. Bath tub rail floor....... .................. E................. ........... ........... ........... ........... ...........
E0243.............. Toilet rail............... .................. E................. ........... ........... ........... ........... ...........
E0244.............. Toilet seat raised........ .................. E................. ........... ........... ........... ........... ...........
E0245.............. Tub stool or bench........ .................. E................. ........... ........... ........... ........... ...........
E0246.............. Transfer tub rail .................. E................. ........... ........... ........... ........... ...........
attachment.
E0247.............. Trans bench w/wo comm open .................. E................. ........... ........... ........... ........... ...........
E0248.............. HDtrans bench w/wo comm .................. E................. ........... ........... ........... ........... ...........
open.
E0249.............. Pad water circulating heat .................. Y................. ........... ........... ........... ........... ...........
u.
E0250.............. Hosp bed fixed ht w/ .................. E................. ........... ........... ........... ........... ...........
mattres.
E0251.............. Hosp bed fixd ht w/o .................. E................. ........... ........... ........... ........... ...........
mattres.
E0255.............. Hospital bed var ht w/ .................. E................. ........... ........... ........... ........... ...........
mattr.
E0256.............. Hospital bed var ht w/o .................. E................. ........... ........... ........... ........... ...........
matt.
E0260.............. Hosp bed semi-electr w/ .................. E................. ........... ........... ........... ........... ...........
matt.
E0261.............. Hosp bed semi-electr w/o .................. E................. ........... ........... ........... ........... ...........
mat.
E0265.............. Hosp bed total electr w/ .................. E................. ........... ........... ........... ........... ...........
mat.
E0266.............. Hosp bed total elec w/o .................. E................. ........... ........... ........... ........... ...........
matt.
E0270.............. Hospital bed institutional .................. E................. ........... ........... ........... ........... ...........
t.
E0271.............. Mattress innerspring...... .................. E................. ........... ........... ........... ........... ...........
E0272.............. Mattress foam rubber...... .................. E................. ........... ........... ........... ........... ...........
E0273.............. Bed board................. .................. E................. ........... ........... ........... ........... ...........
E0274.............. Over-bed table............ .................. E................. ........... ........... ........... ........... ...........
E0275.............. Bed pan standard.......... .................. Y................. ........... ........... ........... ........... ...........
E0276.............. Bed pan fracture.......... .................. Y................. ........... ........... ........... ........... ...........
E0277.............. Powered pres-redu air .................. Y................. ........... ........... ........... ........... ...........
mattrs.
E0280.............. Bed cradle................ .................. Y................. ........... ........... ........... ........... ...........
E0290.............. Hosp bed fx ht w/o rails w/ .................. E................. ........... ........... ........... ........... ...........
m.
E0291.............. Hosp bed fx ht w/o rail w/ .................. Y................. ........... ........... ........... ........... ...........
o.
E0292.............. Hosp bed var ht w/o rail w/ .................. E................. ........... ........... ........... ........... ...........
o.
E0293.............. Hosp bed var ht w/o rail w/ .................. Y................. ........... ........... ........... ........... ...........
.
[[Page 67127]]
E0294.............. Hosp bed semi-elect w/ .................. E................. ........... ........... ........... ........... ...........
mattr.
E0295.............. Hosp bed semi-elect w/o .................. Y................. ........... ........... ........... ........... ...........
matt.
E0296.............. Hosp bed total elect w/ .................. E................. ........... ........... ........... ........... ...........
matt.
E0297.............. Hosp bed total elect w/o .................. Y................. ........... ........... ........... ........... ...........
mat.
E0300.............. Enclosed ped crib hosp .................. Y................. ........... ........... ........... ........... ...........
grade.
E0301.............. HD hosp bed, 350-600 lbs.. .................. Y................. ........... ........... ........... ........... ...........
E0302.............. Ex hd hosp bed > 600 lbs.. .................. Y................. ........... ........... ........... ........... ...........
E0303.............. Hosp bed hvy dty xtra wide .................. E................. ........... ........... ........... ........... ...........
E0304.............. Hosp bed xtra hvy dty x .................. E................. ........... ........... ........... ........... ...........
wide.
E0305.............. Rails bed side half length .................. E................. ........... ........... ........... ........... ...........
E0310.............. Rails bed side full length .................. E................. ........... ........... ........... ........... ...........
E0315.............. Bed accessory brd/tbl/ .................. E................. ........... ........... ........... ........... ...........
supprt.
E0316.............. Bed safety enclosure...... .................. Y................. ........... ........... ........... ........... ...........
E0325.............. Urinal male jug-type...... .................. Y................. ........... ........... ........... ........... ...........
E0326.............. Urinal female jug-type.... .................. Y................. ........... ........... ........... ........... ...........
E0328.............. Ped hospital bed, manual.. NI................ Y................. ........... ........... ........... ........... ...........
E0329.............. Ped hospital bed semi/ NI................ Y................. ........... ........... ........... ........... ...........
elect.
E0350.............. Control unit bowel system. .................. E................. ........... ........... ........... ........... ...........
E0352.............. Disposable pack w/bowel .................. E................. ........... ........... ........... ........... ...........
syst.
E0370.............. Air elevator for heel..... .................. E................. ........... ........... ........... ........... ...........
E0371.............. Nonpower mattress overlay. .................. Y................. ........... ........... ........... ........... ...........
E0372.............. Powered air mattress .................. Y................. ........... ........... ........... ........... ...........
overlay.
E0373.............. Nonpowered pressure .................. Y................. ........... ........... ........... ........... ...........
mattress.
E0424.............. Stationary compressed gas .................. Y................. ........... ........... ........... ........... ...........
02.
E0425.............. Gas system stationary .................. E................. ........... ........... ........... ........... ...........
compre.
E0430.............. Oxygen system gas portable .................. E................. ........... ........... ........... ........... ...........
E0431.............. Portable gaseous 02....... .................. Y................. ........... ........... ........... ........... ...........
E0434.............. Portable liquid 02........ .................. Y................. ........... ........... ........... ........... ...........
E0435.............. Oxygen system liquid .................. E................. ........... ........... ........... ........... ...........
portabl.
E0439.............. Stationary liquid 02...... .................. Y................. ........... ........... ........... ........... ...........
E0440.............. Oxygen system liquid .................. E................. ........... ........... ........... ........... ...........
station.
E0441.............. Oxygen contents, gaseous.. .................. Y................. ........... ........... ........... ........... ...........
E0442.............. Oxygen contents, liquid... .................. Y................. ........... ........... ........... ........... ...........
E0443.............. Portable 02 contents, gas. .................. Y................. ........... ........... ........... ........... ...........
E0444.............. Portable 02 contents, .................. Y................. ........... ........... ........... ........... ...........
liquid.
E0445.............. Oximeter non-invasive..... .................. A................. ........... ........... ........... ........... ...........
E0450.............. Vol control vent invasiv .................. Y................. ........... ........... ........... ........... ...........
int.
E0455.............. Oxygen tent excl croup/ped .................. Y................. ........... ........... ........... ........... ...........
t.
E0457.............. Chest shell............... .................. Y................. ........... ........... ........... ........... ...........
E0459.............. Chest wrap................ .................. Y................. ........... ........... ........... ........... ...........
E0460.............. Neg press vent portabl/ .................. Y................. ........... ........... ........... ........... ...........
statn.
E0461.............. Vol control vent noninv .................. Y................. ........... ........... ........... ........... ...........
int.
E0462.............. Rocking bed w/ or w/o side .................. Y................. ........... ........... ........... ........... ...........
r.
E0463.............. Press supp vent invasive .................. Y................. ........... ........... ........... ........... ...........
int.
E0464.............. Press supp vent noninv int .................. Y................. ........... ........... ........... ........... ...........
E0470.............. RAD w/o backup non-inv .................. Y................. ........... ........... ........... ........... ...........
intfc.
E0471.............. RAD w/backup non inv .................. Y................. ........... ........... ........... ........... ...........
intrfc.
E0472.............. RAD w backup invasive .................. Y................. ........... ........... ........... ........... ...........
intrfc.
E0480.............. Percussor elect/pneum home .................. Y................. ........... ........... ........... ........... ...........
m.
E0481.............. Intrpulmnry percuss vent .................. E................. ........... ........... ........... ........... ...........
sys.
E0482.............. Cough stimulating device.. .................. Y................. ........... ........... ........... ........... ...........
E0483.............. Chest compression gen .................. Y................. ........... ........... ........... ........... ...........
system.
E0484.............. Non-elec oscillatory pep .................. Y................. ........... ........... ........... ........... ...........
dvc.
E0485.............. Oral device/appliance .................. Y................. ........... ........... ........... ........... ...........
prefab.
E0486.............. Oral device/appliance .................. Y................. ........... ........... ........... ........... ...........
cusfab.
E0500.............. Ippb all types............ .................. Y................. ........... ........... ........... ........... ...........
E0550.............. Humidif extens supple w .................. Y................. ........... ........... ........... ........... ...........
ippb.
E0555.............. Humidifier for use w/ .................. Y................. ........... ........... ........... ........... ...........
regula.
E0560.............. Humidifier supplemental w/ .................. Y................. ........... ........... ........... ........... ...........
i.
E0561.............. Humidifier nonheated w PAP .................. Y................. ........... ........... ........... ........... ...........
E0562.............. Humidifier heated used w .................. Y................. ........... ........... ........... ........... ...........
PAP.
E0565.............. Compressor air power .................. Y................. ........... ........... ........... ........... ...........
source.
E0570.............. Nebulizer with compression .................. Y................. ........... ........... ........... ........... ...........
E0571.............. Aerosol compressor for .................. Y................. ........... ........... ........... ........... ...........
svneb.
E0572.............. Aerosol compressor adjust .................. Y................. ........... ........... ........... ........... ...........
pr.
E0574.............. Ultrasonic generator w .................. Y................. ........... ........... ........... ........... ...........
svneb.
E0575.............. Nebulizer ultrasonic...... .................. Y................. ........... ........... ........... ........... ...........
E0580.............. Nebulizer for use w/ .................. Y................. ........... ........... ........... ........... ...........
regulat.
E0585.............. Nebulizer w/ compressor & .................. Y................. ........... ........... ........... ........... ...........
he.
E0600.............. Suction pump portab hom .................. Y................. ........... ........... ........... ........... ...........
modl.
E0601.............. Cont airway pressure .................. Y................. ........... ........... ........... ........... ...........
device.
E0602.............. Manual breast pump........ .................. Y................. ........... ........... ........... ........... ...........
E0603.............. Electric breast pump...... .................. A................. ........... ........... ........... ........... ...........
E0604.............. Hosp grade elec breast .................. A................. ........... ........... ........... ........... ...........
pump.
E0605.............. Vaporizer room type....... .................. Y................. ........... ........... ........... ........... ...........
E0606.............. Drainage board postural... .................. Y................. ........... ........... ........... ........... ...........
E0607.............. Blood glucose monitor home .................. Y................. ........... ........... ........... ........... ...........
E0610.............. Pacemaker monitr audible/ .................. Y................. ........... ........... ........... ........... ...........
vis.
E0615.............. Pacemaker monitr digital/ .................. Y................. ........... ........... ........... ........... ...........
vis.
E0616.............. Cardiac event recorder.... .................. N................. ........... ........... ........... ........... ...........
[[Page 67128]]
E0617.............. Automatic ext .................. Y................. ........... ........... ........... ........... ...........
defibrillator.
E0618.............. Apnea monitor............. .................. A................. ........... ........... ........... ........... ...........
E0619.............. Apnea monitor w recorder.. .................. A................. ........... ........... ........... ........... ...........
E0620.............. Cap bld skin piercing .................. Y................. ........... ........... ........... ........... ...........
laser.
E0621.............. Patient lift sling or seat .................. Y................. ........... ........... ........... ........... ...........
E0625.............. Patient lift bathroom or .................. E................. ........... ........... ........... ........... ...........
toi.
E0627.............. Seat lift incorp lift- .................. Y................. ........... ........... ........... ........... ...........
chair.
E0628.............. Seat lift for pt furn- .................. Y................. ........... ........... ........... ........... ...........
electr.
E0629.............. Seat lift for pt furn-non- .................. Y................. ........... ........... ........... ........... ...........
el.
E0630.............. Patient lift hydraulic.... .................. Y................. ........... ........... ........... ........... ...........
E0635.............. Patient lift electric..... .................. Y................. ........... ........... ........... ........... ...........
E0636.............. PT support & positioning .................. Y................. ........... ........... ........... ........... ...........
sys.
E0637.............. Combination sit to stand .................. E................. ........... ........... ........... ........... ...........
sys.
E0638.............. Standing frame sys........ .................. E................. ........... ........... ........... ........... ...........
E0639.............. Moveable patient lift .................. E................. ........... ........... ........... ........... ...........
system.
E0640.............. Fixed patient lift system. .................. E................. ........... ........... ........... ........... ...........
E0641.............. Multi-position stnd fram .................. E................. ........... ........... ........... ........... ...........
sys.
E0642.............. Dynamic standing frame.... .................. E................. ........... ........... ........... ........... ...........
E0650.............. Pneuma compresor non- .................. Y................. ........... ........... ........... ........... ...........
segment.
E0651.............. Pneum compressor segmental .................. Y................. ........... ........... ........... ........... ...........
E0652.............. Pneum compres w/cal .................. Y................. ........... ........... ........... ........... ...........
pressure.
E0655.............. Pneumatic appliance half .................. Y................. ........... ........... ........... ........... ...........
arm.
E0660.............. Pneumatic appliance full .................. Y................. ........... ........... ........... ........... ...........
leg.
E0665.............. Pneumatic appliance full .................. Y................. ........... ........... ........... ........... ...........
arm.
E0666.............. Pneumatic appliance half .................. Y................. ........... ........... ........... ........... ...........
leg.
E0667.............. Seg pneumatic appl full .................. Y................. ........... ........... ........... ........... ...........
leg.
E0668.............. Seg pneumatic appl full .................. Y................. ........... ........... ........... ........... ...........
arm.
E0669.............. Seg pneumatic appli half .................. Y................. ........... ........... ........... ........... ...........
leg.
E0671.............. Pressure pneum appl full .................. Y................. ........... ........... ........... ........... ...........
leg.
E0672.............. Pressure pneum appl full .................. Y................. ........... ........... ........... ........... ...........
arm.
E0673.............. Pressure pneum appl half .................. Y................. ........... ........... ........... ........... ...........
leg.
E0675.............. Pneumatic compression .................. Y................. ........... ........... ........... ........... ...........
device.
E0676.............. Inter limb compress dev .................. Y................. ........... ........... ........... ........... ...........
NOS.
E0691.............. Uvl pnl 2 sq ft or less... .................. Y................. ........... ........... ........... ........... ...........
E0692.............. Uvl sys panel 4 ft........ .................. Y................. ........... ........... ........... ........... ...........
E0693.............. Uvl sys panel 6 ft........ .................. Y................. ........... ........... ........... ........... ...........
E0694.............. Uvl md cabinet sys 6 ft... .................. Y................. ........... ........... ........... ........... ...........
E0700.............. Safety equipment.......... .................. E................. ........... ........... ........... ........... ...........
E0705.............. Transfer device........... .................. B................. ........... ........... ........... ........... ...........
E0710.............. Restraints any type....... .................. E................. ........... ........... ........... ........... ...........
E0720.............. Tens two lead............. .................. Y................. ........... ........... ........... ........... ...........
E0730.............. Tens four lead............ .................. Y................. ........... ........... ........... ........... ...........
E0731.............. Conductive garment for .................. Y................. ........... ........... ........... ........... ...........
tens/.
E0740.............. Incontinence treatment .................. Y................. ........... ........... ........... ........... ...........
systm.
E0744.............. Neuromuscular stim for .................. Y................. ........... ........... ........... ........... ...........
scoli.
E0745.............. Neuromuscular stim for .................. Y................. ........... ........... ........... ........... ...........
shock.
E0746.............. Electromyograph .................. A................. ........... ........... ........... ........... ...........
biofeedback.
E0747.............. Elec osteogen stim not .................. Y................. ........... ........... ........... ........... ...........
spine.
E0748.............. Elec osteogen stim spinal. .................. Y................. ........... ........... ........... ........... ...........
E0749.............. Elec osteogen stim .................. N................. ........... ........... ........... ........... ...........
implanted.
E0755.............. Electronic salivary reflex .................. E................. ........... ........... ........... ........... ...........
s.
E0760.............. Osteogen ultrasound .................. Y................. ........... ........... ........... ........... ...........
stimltor.
E0761.............. Nontherm electromgntc .................. E................. ........... ........... ........... ........... ...........
device.
E0762.............. Trans elec jt stim dev sys .................. B................. ........... ........... ........... ........... ...........
E0764.............. Functional .................. Y................. ........... ........... ........... ........... ...........
neuromuscularstim.
E0765.............. Nerve stimulator for tx .................. Y................. ........... ........... ........... ........... ...........
n&v.
E0769.............. Electric wound treatment .................. B................. ........... ........... ........... ........... ...........
dev.
E0776.............. Iv pole................... .................. Y................. ........... ........... ........... ........... ...........
E0779.............. Amb infusion pump .................. Y................. ........... ........... ........... ........... ...........
mechanical.
E0780.............. Mech amb infusion pump .................. Y................. ........... ........... ........... ........... ...........
<8hrs.
E0781.............. External ambulatory infus .................. Y................. ........... ........... ........... ........... ...........
pu.
E0782.............. Non-programble infusion .................. N................. ........... ........... ........... ........... ...........
pump.
E0783.............. Programmable infusion pump .................. N................. ........... ........... ........... ........... ...........
E0784.............. Ext amb infusn pump .................. Y................. ........... ........... ........... ........... ...........
insulin.
E0785.............. Replacement impl pump .................. N................. ........... ........... ........... ........... ...........
cathet.
E0786.............. Implantable pump .................. N................. ........... ........... ........... ........... ...........
replacement.
E0791.............. Parenteral infusion pump .................. Y................. ........... ........... ........... ........... ...........
sta.
E0830.............. Ambulatory traction device .................. N................. ........... ........... ........... ........... ...........
E0840.............. Tract frame attach .................. Y................. ........... ........... ........... ........... ...........
headboard.
E0849.............. Cervical pneum trac equip. .................. Y................. ........... ........... ........... ........... ...........
E0850.............. Traction stand free .................. Y................. ........... ........... ........... ........... ...........
standing.
E0855.............. Cervical traction .................. Y................. ........... ........... ........... ........... ...........
equipment.
E0856.............. Cervic collar w air NI................ Y................. ........... ........... ........... ........... ...........
bladder.
E0860.............. Tract equip cervical tract .................. Y................. ........... ........... ........... ........... ...........
E0870.............. Tract frame attach .................. Y................. ........... ........... ........... ........... ...........
footboard.
E0880.............. Trac stand free stand .................. Y................. ........... ........... ........... ........... ...........
extrem.
E0890.............. Traction frame attach .................. Y................. ........... ........... ........... ........... ...........
pelvic.
E0900.............. Trac stand free stand .................. Y................. ........... ........... ........... ........... ...........
pelvic.
E0910.............. Trapeze bar attached to .................. Y................. ........... ........... ........... ........... ...........
bed.
E0911.............. HD trapeze bar attach to .................. Y................. ........... ........... ........... ........... ...........
bed.
[[Page 67129]]
E0912.............. HD trapeze bar free .................. Y................. ........... ........... ........... ........... ...........
standing.
E0920.............. Fracture frame attached to .................. Y................. ........... ........... ........... ........... ...........
b.
E0930.............. Fracture frame free .................. Y................. ........... ........... ........... ........... ...........
standing.
E0935.............. Cont pas motion exercise .................. Y................. ........... ........... ........... ........... ...........
dev.
E0936.............. CPM device, other than .................. E................. ........... ........... ........... ........... ...........
knee.
E0940.............. Trapeze bar free standing. .................. Y................. ........... ........... ........... ........... ...........
E0941.............. Gravity assisted traction .................. Y................. ........... ........... ........... ........... ...........
de.
E0942.............. Cervical head harness/ .................. Y................. ........... ........... ........... ........... ...........
halter.
E0944.............. Pelvic belt/harness/boot.. .................. Y................. ........... ........... ........... ........... ...........
E0945.............. Belt/harness extremity.... .................. Y................. ........... ........... ........... ........... ...........
E0946.............. Fracture frame dual w .................. Y................. ........... ........... ........... ........... ...........
cross.
E0947.............. Fracture frame attachmnts .................. Y................. ........... ........... ........... ........... ...........
pe.
E0948.............. Fracture frame attachmnts .................. Y................. ........... ........... ........... ........... ...........
ce.
E0950.............. Tray...................... .................. A................. ........... ........... ........... ........... ...........
E0951.............. Loop heel................. .................. A................. ........... ........... ........... ........... ...........
E0952.............. Toe loop/holder, each..... .................. A................. ........... ........... ........... ........... ...........
E0955.............. Cushioned headrest........ .................. Y................. ........... ........... ........... ........... ...........
E0956.............. W/c lateral trunk/hip .................. Y................. ........... ........... ........... ........... ...........
suppor.
E0957.............. W/c medial thigh support.. .................. Y................. ........... ........... ........... ........... ...........
E0958.............. Whlchr att- conv 1 arm .................. A................. ........... ........... ........... ........... ...........
drive.
E0959.............. Amputee adapter........... .................. B................. ........... ........... ........... ........... ...........
E0960.............. W/c shoulder harness/ .................. Y................. ........... ........... ........... ........... ...........
straps.
E0961.............. Wheelchair brake extension .................. B................. ........... ........... ........... ........... ...........
E0966.............. Wheelchair head rest .................. B................. ........... ........... ........... ........... ...........
extensi.
E0967.............. Manual wc hand rim w .................. Y................. ........... ........... ........... ........... ...........
project.
E0968.............. Wheelchair commode seat... .................. Y................. ........... ........... ........... ........... ...........
E0969.............. Wheelchair narrowing .................. Y................. ........... ........... ........... ........... ...........
device.
E0970.............. Wheelchair no. 2 CH................ E................. ........... ........... ........... ........... ...........
footplates.
E0971.............. Wheelchair anti-tipping .................. B................. ........... ........... ........... ........... ...........
devi.
E0973.............. W/Ch access det adj .................. B................. ........... ........... ........... ........... ...........
armrest.
E0974.............. W/Ch access anti-rollback. .................. B................. ........... ........... ........... ........... ...........
E0978.............. W/C acc,saf belt pelv .................. B................. ........... ........... ........... ........... ...........
strap.
E0980.............. Wheelchair safety vest.... .................. Y................. ........... ........... ........... ........... ...........
E0981.............. Seat upholstery, .................. Y................. ........... ........... ........... ........... ...........
replacement.
E0982.............. Back upholstery, .................. Y................. ........... ........... ........... ........... ...........
replacement.
E0983.............. Add pwr joystick.......... .................. Y................. ........... ........... ........... ........... ...........
E0984.............. Add pwr tiller............ .................. Y................. ........... ........... ........... ........... ...........
E0985.............. W/c seat lift mechanism... .................. Y................. ........... ........... ........... ........... ...........
E0986.............. Man w/c push-rim pow .................. Y................. ........... ........... ........... ........... ...........
assist.
E0990.............. Wheelchair elevating leg .................. B................. ........... ........... ........... ........... ...........
res.
E0992.............. Wheelchair solid seat .................. B................. ........... ........... ........... ........... ...........
insert.
E0994.............. Wheelchair arm rest....... .................. Y................. ........... ........... ........... ........... ...........
E0995.............. Wheelchair calf rest...... .................. B................. ........... ........... ........... ........... ...........
E1002.............. Pwr seat tilt............. .................. Y................. ........... ........... ........... ........... ...........
E1003.............. Pwr seat recline.......... .................. Y................. ........... ........... ........... ........... ...........
E1004.............. Pwr seat recline mech..... .................. Y................. ........... ........... ........... ........... ...........
E1005.............. Pwr seat recline pwr...... .................. Y................. ........... ........... ........... ........... ...........
E1006.............. Pwr seat combo w/o shear.. .................. Y................. ........... ........... ........... ........... ...........
E1007.............. Pwr seat combo w/shear.... .................. Y................. ........... ........... ........... ........... ...........
E1008.............. Pwr seat combo pwr shear.. .................. Y................. ........... ........... ........... ........... ...........
E1009.............. Add mech leg elevation.... .................. Y................. ........... ........... ........... ........... ...........
E1010.............. Add pwr leg elevation..... .................. Y................. ........... ........... ........... ........... ...........
E1011.............. Ped wc modify width .................. Y................. ........... ........... ........... ........... ...........
adjustm.
E1014.............. Reclining back add ped w/c .................. Y................. ........... ........... ........... ........... ...........
E1015.............. Shock absorber for man w/c .................. Y................. ........... ........... ........... ........... ...........
E1016.............. Shock absorber for power w/ .................. Y................. ........... ........... ........... ........... ...........
c.
E1017.............. HD shck absrbr for hd man .................. Y................. ........... ........... ........... ........... ...........
wc.
E1018.............. HD shck absrber for hd .................. Y................. ........... ........... ........... ........... ...........
powwc.
E1020.............. Residual limb support .................. Y................. ........... ........... ........... ........... ...........
system.
E1028.............. W/c manual swingaway...... .................. Y................. ........... ........... ........... ........... ...........
E1029.............. W/c vent tray fixed....... .................. Y................. ........... ........... ........... ........... ...........
E1030.............. W/c vent tray gimbaled.... .................. Y................. ........... ........... ........... ........... ...........
E1031.............. Rollabout chair with .................. Y................. ........... ........... ........... ........... ...........
casters.
E1035.............. Patient transfer system... .................. Y................. ........... ........... ........... ........... ...........
E1037.............. Transport chair, ped size. .................. Y................. ........... ........... ........... ........... ...........
E1038.............. Transport chair pt .................. Y................. ........... ........... ........... ........... ...........
wt<=300lb.
E1039.............. Transport chair pt wt .................. Y................. ........... ........... ........... ........... ...........
>300lb.
E1050.............. Whelchr fxd full length .................. A................. ........... ........... ........... ........... ...........
arms.
E1060.............. Wheelchair detachable arms .................. A................. ........... ........... ........... ........... ...........
E1070.............. Wheelchair detachable foot .................. A................. ........... ........... ........... ........... ...........
r.
E1083.............. Hemi-wheelchair fixed arms .................. A................. ........... ........... ........... ........... ...........
E1084.............. Hemi-wheelchair detachable .................. A................. ........... ........... ........... ........... ...........
a.
E1085.............. Hemi-wheelchair fixed arms CH................ E................. ........... ........... ........... ........... ...........
E1086.............. Hemi-wheelchair detachable CH................ E................. ........... ........... ........... ........... ...........
a.
E1087.............. Wheelchair lightwt fixed .................. A................. ........... ........... ........... ........... ...........
arm.
E1088.............. Wheelchair lightweight det .................. A................. ........... ........... ........... ........... ...........
a.
E1089.............. Wheelchair lightwt fixed CH................ E................. ........... ........... ........... ........... ...........
arm.
E1090.............. Wheelchair lightweight det CH................ E................. ........... ........... ........... ........... ...........
a.
E1092.............. Wheelchair wide w/ leg .................. A................. ........... ........... ........... ........... ...........
rests.
E1093.............. Wheelchair wide w/ foot .................. A................. ........... ........... ........... ........... ...........
rest.
[[Page 67130]]
E1100.............. Whchr s-recl fxd arm leg .................. A................. ........... ........... ........... ........... ...........
res.
E1110.............. Wheelchair semi-recl .................. A................. ........... ........... ........... ........... ...........
detach.
E1130.............. Whlchr stand fxd arm ft CH................ E................. ........... ........... ........... ........... ...........
rest.
E1140.............. Wheelchair standard detach CH................ E................. ........... ........... ........... ........... ...........
a.
E1150.............. Wheelchair standard w/ leg .................. Y................. ........... ........... ........... ........... ...........
r.
E1160.............. Wheelchair fixed arms..... .................. A................. ........... ........... ........... ........... ...........
E1161.............. Manual adult wc w .................. A................. ........... ........... ........... ........... ...........
tiltinspac.
E1170.............. Whlchr ampu fxd arm leg .................. A................. ........... ........... ........... ........... ...........
rest.
E1171.............. Wheelchair amputee w/o leg .................. A................. ........... ........... ........... ........... ...........
r.
E1172.............. Wheelchair amputee detach .................. A................. ........... ........... ........... ........... ...........
ar.
E1180.............. Wheelchair amputee w/ foot .................. A................. ........... ........... ........... ........... ...........
r.
E1190.............. Wheelchair amputee w/ leg .................. A................. ........... ........... ........... ........... ...........
re.
E1195.............. Wheelchair amputee heavy .................. A................. ........... ........... ........... ........... ...........
dut.
E1200.............. Wheelchair amputee fixed .................. A................. ........... ........... ........... ........... ...........
arm.
E1220.............. Whlchr special size/ .................. A................. ........... ........... ........... ........... ...........
constrc.
E1221.............. Wheelchair spec size w .................. A................. ........... ........... ........... ........... ...........
foot.
E1222.............. Wheelchair spec size w/ .................. A................. ........... ........... ........... ........... ...........
leg.
E1223.............. Wheelchair spec size w .................. A................. ........... ........... ........... ........... ...........
foot.
E1224.............. Wheelchair spec size w/ .................. A................. ........... ........... ........... ........... ...........
leg.
E1225.............. Manual semi-reclining back .................. Y................. ........... ........... ........... ........... ...........
E1226.............. Manual fully reclining .................. B................. ........... ........... ........... ........... ...........
back.
E1227.............. Wheelchair spec sz spec ht .................. Y................. ........... ........... ........... ........... ...........
a.
E1228.............. Wheelchair spec sz spec ht .................. Y................. ........... ........... ........... ........... ...........
b.
E1229.............. Pediatric wheelchair NOS.. .................. Y................. ........... ........... ........... ........... ...........
E1230.............. Power operated vehicle.... .................. Y................. ........... ........... ........... ........... ...........
E1231.............. Rigid ped w/c tilt-in- .................. Y................. ........... ........... ........... ........... ...........
space.
E1232.............. Folding ped wc tilt-in- .................. Y................. ........... ........... ........... ........... ...........
space.
E1233.............. Rig ped wc tltnspc w/o .................. Y................. ........... ........... ........... ........... ...........
seat.
E1234.............. Fld ped wc tltnspc w/o .................. Y................. ........... ........... ........... ........... ...........
seat.
E1235.............. Rigid ped wc adjustable... .................. Y................. ........... ........... ........... ........... ...........
E1236.............. Folding ped wc adjustable. .................. Y................. ........... ........... ........... ........... ...........
E1237.............. Rgd ped wc adjstabl w/o .................. Y................. ........... ........... ........... ........... ...........
seat.
E1238.............. Fld ped wc adjstabl w/o .................. Y................. ........... ........... ........... ........... ...........
seat.
E1239.............. Ped power wheelchair NOS.. .................. Y................. ........... ........... ........... ........... ...........
E1240.............. Whchr litwt det arm leg .................. A................. ........... ........... ........... ........... ...........
rest.
E1250.............. Wheelchair lightwt fixed CH................ E................. ........... ........... ........... ........... ...........
arm.
E1260.............. Wheelchair lightwt foot CH................ E................. ........... ........... ........... ........... ...........
rest.
E1270.............. Wheelchair lightweight leg .................. A................. ........... ........... ........... ........... ...........
r.
E1280.............. Whchr h-duty det arm leg .................. A................. ........... ........... ........... ........... ...........
res.
E1285.............. Wheelchair heavy duty CH................ E................. ........... ........... ........... ........... ...........
fixed.
E1290.............. Wheelchair hvy duty detach CH................ E................. ........... ........... ........... ........... ...........
a.
E1295.............. Wheelchair heavy duty .................. A................. ........... ........... ........... ........... ...........
fixed.
E1296.............. Wheelchair special seat .................. Y................. ........... ........... ........... ........... ...........
heig.
E1297.............. Wheelchair special seat .................. Y................. ........... ........... ........... ........... ...........
dept.
E1298.............. Wheelchair spec seat depth/ .................. Y................. ........... ........... ........... ........... ...........
w.
E1300.............. Whirlpool portable........ .................. E................. ........... ........... ........... ........... ...........
E1310.............. Whirlpool non-portable.... .................. Y................. ........... ........... ........... ........... ...........
E1340.............. Repair for DME, per 15 min .................. Y................. ........... ........... ........... ........... ...........
E1353.............. Oxygen supplies regulator. .................. Y................. ........... ........... ........... ........... ...........
E1355.............. Oxygen supplies stand/rack .................. Y................. ........... ........... ........... ........... ...........
E1372.............. Oxy suppl heater for .................. Y................. ........... ........... ........... ........... ...........
nebuliz.
E1390.............. Oxygen concentrator....... .................. Y................. ........... ........... ........... ........... ...........
E1391.............. Oxygen concentrator, dual. .................. Y................. ........... ........... ........... ........... ...........
E1392.............. Portable oxygen .................. Y................. ........... ........... ........... ........... ...........
concentrator.
E1399.............. Durable medical equipment .................. Y................. ........... ........... ........... ........... ...........
mi.
E1405.............. O2/water vapor enrich w/ .................. Y................. ........... ........... ........... ........... ...........
heat.
E1406.............. O2/water vapor enrich w/o .................. Y................. ........... ........... ........... ........... ...........
he.
E1500.............. Centrifuge................ .................. A................. ........... ........... ........... ........... ...........
E1510.............. Kidney dialysate delivry .................. A................. ........... ........... ........... ........... ...........
sys.
E1520.............. Heparin infusion pump..... .................. A................. ........... ........... ........... ........... ...........
E1530.............. Replacement air bubble .................. A................. ........... ........... ........... ........... ...........
detec.
E1540.............. Replacement pressure alarm .................. A................. ........... ........... ........... ........... ...........
E1550.............. Bath conductivity meter... .................. A................. ........... ........... ........... ........... ...........
E1560.............. Replace blood leak .................. A................. ........... ........... ........... ........... ...........
detector.
E1570.............. Adjustable chair for esrd .................. A................. ........... ........... ........... ........... ...........
pt.
E1575.............. Transducer protect/fld bar .................. A................. ........... ........... ........... ........... ...........
E1580.............. Unipuncture control system .................. A................. ........... ........... ........... ........... ...........
E1590.............. Hemodialysis machine...... .................. A................. ........... ........... ........... ........... ...........
E1592.............. Auto interm peritoneal .................. A................. ........... ........... ........... ........... ...........
dialy.
E1594.............. Cycler dialysis machine... .................. A................. ........... ........... ........... ........... ...........
E1600.............. Deli/install chrg hemo .................. A................. ........... ........... ........... ........... ...........
equip.
E1610.............. Reverse osmosis h2o puri .................. A................. ........... ........... ........... ........... ...........
sys.
E1615.............. Deionizer H2O puri system. .................. A................. ........... ........... ........... ........... ...........
E1620.............. Replacement blood pump.... .................. A................. ........... ........... ........... ........... ...........
E1625.............. Water softening system.... .................. A................. ........... ........... ........... ........... ...........
E1630.............. Reciprocating peritoneal .................. A................. ........... ........... ........... ........... ...........
dia.
E1632.............. Wearable artificial kidney .................. A................. ........... ........... ........... ........... ...........
E1634.............. Peritoneal dialysis clamp. .................. B................. ........... ........... ........... ........... ...........
E1635.............. Compact travel .................. A................. ........... ........... ........... ........... ...........
hemodialyzer.
E1636.............. Sorbent cartridges per 10. .................. A................. ........... ........... ........... ........... ...........
[[Page 67131]]
E1637.............. Hemostats for dialysis, .................. A................. ........... ........... ........... ........... ...........
each.
E1639.............. Dialysis scale............ .................. A................. ........... ........... ........... ........... ...........
E1699.............. Dialysis equipment noc.... .................. A................. ........... ........... ........... ........... ...........
E1700.............. Jaw motion rehab system... .................. Y................. ........... ........... ........... ........... ...........
E1701.............. Repl cushions for jaw .................. Y................. ........... ........... ........... ........... ...........
motion.
E1702.............. Repl measr scales jaw .................. Y................. ........... ........... ........... ........... ...........
motion.
E1800.............. Adjust elbow ext/flex .................. Y................. ........... ........... ........... ........... ...........
device.
E1801.............. SPS elbow device.......... .................. Y................. ........... ........... ........... ........... ...........
E1802.............. Adjst forearm pro/sup .................. Y................. ........... ........... ........... ........... ...........
device.
E1805.............. Adjust wrist ext/flex .................. Y................. ........... ........... ........... ........... ...........
device.
E1806.............. SPS wrist device.......... .................. Y................. ........... ........... ........... ........... ...........
E1810.............. Adjust knee ext/flex .................. Y................. ........... ........... ........... ........... ...........
device.
E1811.............. SPS knee device........... .................. Y................. ........... ........... ........... ........... ...........
E1812.............. Knee ext/flex w act res .................. Y................. ........... ........... ........... ........... ...........
ctrl.
E1815.............. Adjust ankle ext/flex .................. Y................. ........... ........... ........... ........... ...........
device.
E1816.............. SPS ankle device.......... .................. Y................. ........... ........... ........... ........... ...........
E1818.............. SPS forearm device........ .................. Y................. ........... ........... ........... ........... ...........
E1820.............. Soft interface material... .................. Y................. ........... ........... ........... ........... ...........
E1821.............. Replacement interface SPSD .................. Y................. ........... ........... ........... ........... ...........
E1825.............. Adjust finger ext/flex .................. Y................. ........... ........... ........... ........... ...........
devc.
E1830.............. Adjust toe ext/flex device .................. Y................. ........... ........... ........... ........... ...........
E1840.............. Adj shoulder ext/flex .................. Y................. ........... ........... ........... ........... ...........
device.
E1841.............. Static str shldr dev rom .................. Y................. ........... ........... ........... ........... ...........
adj.
E1902.............. AAC non-electronic board.. .................. A................. ........... ........... ........... ........... ...........
E2000.............. Gastric suction pump hme .................. Y................. ........... ........... ........... ........... ...........
mdl.
E2100.............. Bld glucose monitor w .................. Y................. ........... ........... ........... ........... ...........
voice.
E2101.............. Bld glucose monitor w .................. Y................. ........... ........... ........... ........... ...........
lance.
E2120.............. Pulse gen sys tx endolymp .................. Y................. ........... ........... ........... ........... ...........
fl.
E2201.............. Man w/ch acc seat w>=20/ .................. Y................. ........... ........... ........... ........... ...........
<24/.
E2202.............. Seat width 24-27 in....... .................. Y................. ........... ........... ........... ........... ...........
E2203.............. Frame depth less than 22 .................. Y................. ........... ........... ........... ........... ...........
in.
E2204.............. Frame depth 22 to 25 in... .................. Y................. ........... ........... ........... ........... ...........
E2205.............. Manual wc accessory, .................. Y................. ........... ........... ........... ........... ...........
handrim.
E2206.............. Complete wheel lock .................. Y................. ........... ........... ........... ........... ...........
assembly.
E2207.............. Crutch and cane holder.... .................. Y................. ........... ........... ........... ........... ...........
E2208.............. Cylinder tank carrier..... .................. Y................. ........... ........... ........... ........... ...........
E2209.............. Arm trough each........... .................. Y................. ........... ........... ........... ........... ...........
E2210.............. Wheelchair bearings....... .................. Y................. ........... ........... ........... ........... ...........
E2211.............. Pneumatic propulsion tire. .................. Y................. ........... ........... ........... ........... ...........
E2212.............. Pneumatic prop tire tube.. .................. Y................. ........... ........... ........... ........... ...........
E2213.............. Pneumatic prop tire insert .................. Y................. ........... ........... ........... ........... ...........
E2214.............. Pneumatic caster tire each .................. Y................. ........... ........... ........... ........... ...........
E2215.............. Pneumatic caster tire tube .................. Y................. ........... ........... ........... ........... ...........
E2216.............. Foam filled propulsion .................. Y................. ........... ........... ........... ........... ...........
tire.
E2217.............. Foam filled caster tire .................. Y................. ........... ........... ........... ........... ...........
each.
E2218.............. Foam propulsion tire each. .................. Y................. ........... ........... ........... ........... ...........
E2219.............. Foam caster tire any size .................. Y................. ........... ........... ........... ........... ...........
ea.
E2220.............. Solid propulsion tire each .................. Y................. ........... ........... ........... ........... ...........
E2221.............. Solid caster tire each.... .................. Y................. ........... ........... ........... ........... ...........
E2222.............. Solid caster integrated .................. Y................. ........... ........... ........... ........... ...........
whl.
E2223.............. Valve replacement only .................. Y................. ........... ........... ........... ........... ...........
each.
E2224.............. Propulsion whl excludes .................. Y................. ........... ........... ........... ........... ...........
tire.
E2225.............. Caster wheel excludes tire .................. Y................. ........... ........... ........... ........... ...........
E2226.............. Caster fork replacement .................. Y................. ........... ........... ........... ........... ...........
only.
E2227.............. Gear reduction drive wheel NI................ Y................. ........... ........... ........... ........... ...........
E2228.............. Mwc acc, wheelchair brake. NI................ Y................. ........... ........... ........... ........... ...........
E2291.............. Planar back for ped size .................. Y................. ........... ........... ........... ........... ...........
wc.
E2292.............. Planar seat for ped size .................. Y................. ........... ........... ........... ........... ...........
wc.
E2293.............. Contour back for ped size .................. Y................. ........... ........... ........... ........... ...........
wc.
E2294.............. Contour seat for ped size .................. Y................. ........... ........... ........... ........... ...........
wc.
E2300.............. Pwr seat elevation sys.... .................. Y................. ........... ........... ........... ........... ...........
E2301.............. Pwr standing.............. .................. Y................. ........... ........... ........... ........... ...........
E2310.............. Electro connect btw .................. Y................. ........... ........... ........... ........... ...........
control.
E2311.............. Electro connect btw 2 sys. .................. Y................. ........... ........... ........... ........... ...........
E2312.............. Mini-prop remote joystick. NI................ Y................. ........... ........... ........... ........... ...........
E2313.............. PWC harness, expand NI................ Y................. ........... ........... ........... ........... ...........
control.
E2321.............. Hand interface joystick... .................. Y................. ........... ........... ........... ........... ...........
E2322.............. Mult mech switches........ .................. Y................. ........... ........... ........... ........... ...........
E2323.............. Special joystick handle... .................. Y................. ........... ........... ........... ........... ...........
E2324.............. Chin cup interface........ .................. Y................. ........... ........... ........... ........... ...........
E2325.............. Sip and puff interface.... .................. Y................. ........... ........... ........... ........... ...........
E2326.............. Breath tube kit........... .................. Y................. ........... ........... ........... ........... ...........
E2327.............. Head control interface .................. Y................. ........... ........... ........... ........... ...........
mech.
E2328.............. Head/extremity control .................. Y................. ........... ........... ........... ........... ...........
inter.
E2329.............. Head control .................. Y................. ........... ........... ........... ........... ...........
nonproportional.
E2330.............. Head control proximity .................. Y................. ........... ........... ........... ........... ...........
switc.
E2331.............. Attendant control......... .................. Y................. ........... ........... ........... ........... ...........
E2340.............. W/c wdth 20-23 in seat .................. Y................. ........... ........... ........... ........... ...........
frame.
E2341.............. W/c wdth 24-27 in seat .................. Y................. ........... ........... ........... ........... ...........
frame.
E2342.............. W/c dpth 20-21 in seat .................. Y................. ........... ........... ........... ........... ...........
frame.
[[Page 67132]]
E2343.............. W/c dpth 22-25 in seat .................. Y................. ........... ........... ........... ........... ...........
frame.
E2351.............. Electronic SGD interface.. .................. Y................. ........... ........... ........... ........... ...........
E2360.............. 22nf nonsealed leadacid... .................. Y................. ........... ........... ........... ........... ...........
E2361.............. 22nf sealed leadacid .................. Y................. ........... ........... ........... ........... ...........
battery.
E2362.............. Gr24 nonsealed leadacid... .................. Y................. ........... ........... ........... ........... ...........
E2363.............. Gr24 sealed leadacid .................. Y................. ........... ........... ........... ........... ...........
battery.
E2364.............. U1nonsealed leadacid .................. Y................. ........... ........... ........... ........... ...........
battery.
E2365.............. U1 sealed leadacid battery .................. Y................. ........... ........... ........... ........... ...........
E2366.............. Battery charger, single .................. Y................. ........... ........... ........... ........... ...........
mode.
E2367.............. Battery charger, dual mode .................. Y................. ........... ........... ........... ........... ...........
E2368.............. Power wc motor replacement .................. Y................. ........... ........... ........... ........... ...........
E2369.............. Pwr wc gear box .................. Y................. ........... ........... ........... ........... ...........
replacement.
E2370.............. Pwr wc motor/gear box .................. Y................. ........... ........... ........... ........... ...........
combo.
E2371.............. Gr27 sealed leadacid .................. Y................. ........... ........... ........... ........... ...........
battery.
E2372.............. Gr27 non-sealed leadacid.. .................. Y................. ........... ........... ........... ........... ...........
E2373.............. Hand/chin ctrl spec .................. Y................. ........... ........... ........... ........... ...........
joystick.
E2374.............. Hand/chin ctrl std .................. Y................. ........... ........... ........... ........... ...........
joystick.
E2375.............. Non-expandable controller. .................. Y................. ........... ........... ........... ........... ...........
E2376.............. Expandable controller, .................. Y................. ........... ........... ........... ........... ...........
repl.
E2377.............. Expandable controller, .................. Y................. ........... ........... ........... ........... ...........
initl.
E2381.............. Pneum drive wheel tire.... .................. Y................. ........... ........... ........... ........... ...........
E2382.............. Tube, pneum wheel drive .................. Y................. ........... ........... ........... ........... ...........
tire.
E2383.............. Insert, pneum wheel drive. .................. Y................. ........... ........... ........... ........... ...........
E2384.............. Pneumatic caster tire..... .................. Y................. ........... ........... ........... ........... ...........
E2385.............. Tube, pneumatic caster .................. Y................. ........... ........... ........... ........... ...........
tire.
E2386.............. Foam filled drive wheel .................. Y................. ........... ........... ........... ........... ...........
tire.
E2387.............. Foam filled caster tire... .................. Y................. ........... ........... ........... ........... ...........
E2388.............. Foam drive wheel tire..... .................. Y................. ........... ........... ........... ........... ...........
E2389.............. Foam caster tire.......... .................. Y................. ........... ........... ........... ........... ...........
E2390.............. Solid drive wheel tire.... .................. Y................. ........... ........... ........... ........... ...........
E2391.............. Solid caster tire......... .................. Y................. ........... ........... ........... ........... ...........
E2392.............. Solid caster tire, .................. Y................. ........... ........... ........... ........... ...........
integrate.
E2393.............. Valve, pneumatic tire tube .................. Y................. ........... ........... ........... ........... ...........
E2394.............. Drive wheel excludes tire. .................. Y................. ........... ........... ........... ........... ...........
E2395.............. Caster wheel excludes tire .................. Y................. ........... ........... ........... ........... ...........
E2396.............. Caster fork............... .................. Y................. ........... ........... ........... ........... ...........
E2397.............. Pwc acc, lith-based NI................ Y................. ........... ........... ........... ........... ...........
battery.
E2399.............. Noc interface............. .................. Y................. ........... ........... ........... ........... ...........
E2402.............. Neg press wound therapy .................. Y................. ........... ........... ........... ........... ...........
pump.
E2500.............. SGD digitized pre-rec .................. Y................. ........... ........... ........... ........... ...........
<=8min.
E2502.............. SGD prerec msg >8min .................. Y................. ........... ........... ........... ........... ...........
<=20min.
E2504.............. SGD prerec msg>20min .................. Y................. ........... ........... ........... ........... ...........
<=40min.
E2506.............. SGD prerec msg > 40 min... .................. Y................. ........... ........... ........... ........... ...........
E2508.............. SGD spelling phys contact. .................. Y................. ........... ........... ........... ........... ...........
E2510.............. SGD w multi methods msg/ .................. Y................. ........... ........... ........... ........... ...........
accs.
E2511.............. SGD sftwre prgrm for PC/ .................. Y................. ........... ........... ........... ........... ...........
PDA.
E2512.............. SGD accessory, mounting .................. Y................. ........... ........... ........... ........... ...........
sys.
E2599.............. SGD accessory noc......... .................. Y................. ........... ........... ........... ........... ...........
E2601.............. Gen w/c cushion wdth < 22 .................. Y................. ........... ........... ........... ........... ...........
in.
E2602.............. Gen w/c cushion wdth >=22 .................. Y................. ........... ........... ........... ........... ...........
in.
E2603.............. Skin protect wc cus wd .................. Y................. ........... ........... ........... ........... ...........
<22in.
E2604.............. Skin protect wc cus .................. Y................. ........... ........... ........... ........... ...........
wd>=22in.
E2605.............. Position wc cush wdth <22 .................. Y................. ........... ........... ........... ........... ...........
in.
E2606.............. Position wc cush wdth>=22 .................. Y................. ........... ........... ........... ........... ...........
in.
E2607.............. Skin pro/pos wc cus wd .................. Y................. ........... ........... ........... ........... ...........
<22in.
E2608.............. Skin pro/pos wc cus .................. Y................. ........... ........... ........... ........... ...........
wd>=22in.
E2609.............. Custom fabricate w/c .................. Y................. ........... ........... ........... ........... ...........
cushion.
E2610.............. Powered w/c cushion....... .................. B................. ........... ........... ........... ........... ...........
E2611.............. Gen use back cush wdth .................. Y................. ........... ........... ........... ........... ...........
<22in.
E2612.............. Gen use back cush .................. Y................. ........... ........... ........... ........... ...........
wdth>=22in.
E2613.............. Position back cush wd .................. Y................. ........... ........... ........... ........... ...........
<22in.
E2614.............. Position back cush .................. Y................. ........... ........... ........... ........... ...........
wd>=22in.
E2615.............. Pos back post/lat wdth .................. Y................. ........... ........... ........... ........... ...........
<22in.
E2616.............. Pos back post/lat .................. Y................. ........... ........... ........... ........... ...........
wdth>=22in.
E2617.............. Custom fab w/c back .................. Y................. ........... ........... ........... ........... ...........
cushion.
E2618.............. Wc acc solid seat supp CH................ D................. ........... ........... ........... ........... ...........
base.
E2619.............. Replace cover w/c seat .................. Y................. ........... ........... ........... ........... ...........
cush.
E2620.............. WC planar back cush wd .................. Y................. ........... ........... ........... ........... ...........
<22in.
E2621.............. WC planar back cush .................. Y................. ........... ........... ........... ........... ...........
wd>=22in.
E8000.............. Posterior gait trainer.... .................. E................. ........... ........... ........... ........... ...........
E8001.............. Upright gait trainer...... .................. E................. ........... ........... ........... ........... ...........
E8002.............. Anterior gait trainer..... .................. E................. ........... ........... ........... ........... ...........
G0008.............. Admin influenza virus vac. .................. S................. 0350 0.3945 $25.13 ........... ...........
G0009.............. Admin pneumococcal vaccine .................. S................. 0350 0.3945 $25.13 ........... ...........
G0010.............. Admin hepatitis b vaccine. .................. B................. ........... ........... ........... ........... ...........
G0027.............. Semen analysis............ .................. A................. ........... ........... ........... ........... ...........
G0101.............. CA screen;pelvic/breast .................. V................. 0604 0.8388 $53.43 ........... $10.69
exam.
G0102.............. Prostate ca screening; dre .................. N................. ........... ........... ........... ........... ...........
G0103.............. PSA screening............. .................. A................. ........... ........... ........... ........... ...........
G0104.............. CA screen;flexi .................. S................. 0159 4.7010 $299.43 ........... $74.86
sigmoidscope.
[[Page 67133]]
G0105.............. Colorectal scrn; hi risk .................. T................. 0158 7.8504 $500.02 ........... $125.01
ind.
G0106.............. Colon CA screen;barium .................. S................. 0157 2.0651 $131.53 ........... $26.31
enema.
G0108.............. Diab manage trn per indiv. .................. A................. ........... ........... ........... ........... ...........
G0109.............. Diab manage trn ind/group. .................. A................. ........... ........... ........... ........... ...........
G0117.............. Glaucoma scrn hgh risk CH................ S................. 0698 0.8696 $55.39 ........... $11.08
direc.
G0118.............. Glaucoma scrn hgh risk .................. S................. 0230 0.5903 $37.60 ........... $7.52
direc.
G0120.............. Colon ca scrn; barium .................. S................. 0157 2.0651 $131.53 ........... $26.31
enema.
G0121.............. Colon ca scrn not hi rsk .................. T................. 0158 7.8504 $500.02 ........... $125.01
ind.
G0122.............. Colon ca scrn; barium .................. E................. ........... ........... ........... ........... ...........
enema.
G0123.............. Screen cerv/vag thin layer .................. A................. ........... ........... ........... ........... ...........
G0124.............. Screen c/v thin layer by .................. B................. ........... ........... ........... ........... ...........
MD.
G0127.............. Trim nail(s).............. CH................ T................. 0013 0.7930 $50.51 ........... $10.10
G0128.............. CORF skilled nursing .................. B................. ........... ........... ........... ........... ...........
service.
G0129.............. Partial hosp prog service. .................. P................. 0033 ........... ........... ........... ...........
G0130.............. Single energy x-ray study. .................. X................. 0260 0.6954 $44.29 ........... $8.86
G0141.............. Scr c/v cyto,autosys and .................. B................. ........... ........... ........... ........... ...........
md.
G0143.............. Scr c/v .................. A................. ........... ........... ........... ........... ...........
cyto,thinlayer,rescr.
G0144.............. Scr c/v .................. A................. ........... ........... ........... ........... ...........
cyto,thinlayer,rescr.
G0145.............. Scr c/v .................. A................. ........... ........... ........... ........... ...........
cyto,thinlayer,rescr.
G0147.............. Scr c/v cyto, automated .................. A................. ........... ........... ........... ........... ...........
sys.
G0148.............. Scr c/v cyto, autosys, .................. A................. ........... ........... ........... ........... ...........
rescr.
G0151.............. HHCP-serv of pt,ea 15 min. .................. B................. ........... ........... ........... ........... ...........
G0152.............. HHCP-serv of ot,ea 15 min. .................. B................. ........... ........... ........... ........... ...........
G0153.............. HHCP-svs of s/l path,ea .................. B................. ........... ........... ........... ........... ...........
15mn.
G0154.............. HHCP-svs of rn,ea 15 min.. .................. B................. ........... ........... ........... ........... ...........
G0155.............. HHCP-svs of csw,ea 15 min. .................. B................. ........... ........... ........... ........... ...........
G0156.............. HHCP-svs of aide,ea 15 min .................. B................. ........... ........... ........... ........... ...........
G0166.............. Extrnl counterpulse, per .................. T................. 0678 1.7187 $109.47 ........... $21.89
tx.
G0168.............. Wound closure by adhesive. .................. B................. ........... ........... ........... ........... ...........
G0173.............. Linear acc stereo radsur .................. S................. 0067 61.6965 $3,929.70 ........... $785.94
com.
G0175.............. OPPS Service,sched team .................. V................. 0608 2.1740 $138.47 ........... $27.69
conf.
G0176.............. OPPS/PHP;activity therapy. .................. P................. 0033 ........... ........... ........... ...........
G0177.............. OPPS/PHP; train & educ CH................ N................. ........... ........... ........... ........... ...........
serv.
G0179.............. MD recertification HHA PT. .................. M................. ........... ........... ........... ........... ...........
G0180.............. MD certification HHA .................. M................. ........... ........... ........... ........... ...........
patient.
G0181.............. Home health care .................. M................. ........... ........... ........... ........... ...........
supervision.
G0182.............. Hospice care supervision.. .................. M................. ........... ........... ........... ........... ...........
G0186.............. Dstry eye lesn,fdr vssl .................. T................. 0235 4.1331 $263.25 $58.93 $52.65
tech.
G0202.............. Screeningmammographydigita .................. A................. ........... ........... ........... ........... ...........
l.
G0204.............. Diagnosticmammographydigit .................. A................. ........... ........... ........... ........... ...........
al.
G0206.............. Diagnosticmammographydigit .................. A................. ........... ........... ........... ........... ...........
al.
G0219.............. PET img wholbod melano .................. E................. ........... ........... ........... ........... ...........
nonco.
G0235.............. PET not otherwise .................. E................. ........... ........... ........... ........... ...........
specified.
G0237.............. Therapeutic procd strg CH................ S................. 0077 0.3877 $24.69 $7.74 $4.94
endur.
G0238.............. Oth resp proc, indiv...... CH................ S................. 0077 0.3877 $24.69 $7.74 $4.94
G0239.............. Oth resp proc, group...... CH................ S................. 0077 0.3877 $24.69 $7.74 $4.94
G0245.............. Initial foot exam pt lops. .................. V................. 0604 0.8388 $53.43 ........... $10.69
G0246.............. Followup eval of foot pt .................. V................. 0605 0.9964 $63.46 ........... $12.69
lop.
G0247.............. Routine footcare pt w lops CH................ T................. 0013 0.7930 $50.51 ........... $10.10
G0248.............. Demonstrate use home inr CH................ V................. 0607 1.6604 $105.76 ........... $21.15
mon.
G0249.............. Provide test CH................ V................. 0607 1.6604 $105.76 ........... $21.15
material,equipm.
G0250.............. MD review interpret of .................. M................. ........... ........... ........... ........... ...........
test.
G0251.............. Linear acc based stero .................. S................. 0065 16.5911 $1,056.75 ........... $211.35
radio.
G0252.............. PET imaging initial dx.... .................. E................. ........... ........... ........... ........... ...........
G0255.............. Current percep threshold .................. E................. ........... ........... ........... ........... ...........
tst.
G0257.............. Unsched dialysis ESRD pt .................. S................. 0170 6.5383 $416.45 ........... $83.29
hos.
G0259.............. Inject for sacroiliac .................. N................. ........... ........... ........... ........... ...........
joint.
G0260.............. Inj for sacroiliac jt CH................ T................. 0207 7.0546 $449.34 ........... $89.87
anesth.
G0265.............. Cryopresevation CH................ D................. ........... ........... ........... ........... ...........
Freeze+stora.
G0266.............. Thawing + expansion froz CH................ D................. ........... ........... ........... ........... ...........
cel.
G0267.............. Bone marrow or psc harvest CH................ D................. ........... ........... ........... ........... ...........
G0268.............. Removal of impacted wax md CH................ N................. ........... ........... ........... ........... ...........
G0269.............. Occlusive device in vein .................. N................. ........... ........... ........... ........... ...........
art.
G0270.............. MNT subs tx for change dx. .................. A................. ........... ........... ........... ........... ...........
G0271.............. Group MNT 2 or more 30 .................. A................. ........... ........... ........... ........... ...........
mins.
G0275.............. Renal angio, cardiac cath. .................. N................. ........... ........... ........... ........... ...........
G0278.............. Iliac art angio,cardiac .................. N................. ........... ........... ........... ........... ...........
cath.
G0281.............. Elec stim unattend for .................. A................. ........... ........... ........... ........... ...........
press.
G0282.............. Elect stim wound care not .................. E................. ........... ........... ........... ........... ...........
pd.
G0283.............. Elec stim other than wound .................. A................. ........... ........... ........... ........... ...........
G0288.............. Recon, CTA for surg plan.. CH................ N................. ........... ........... ........... ........... ...........
G0289.............. Arthro, loose body + .................. N................. ........... ........... ........... ........... ...........
chondro.
G0290.............. Drug-eluting stents, .................. T................. 0656 118.4265 $7,543.06 ........... $1,508.61
single.
G0291.............. Drug-eluting stents,each .................. T................. 0656 118.4265 $7,543.06 ........... $1,508.61
add.
G0293.............. Non-cov surg proc,clin .................. X................. 0340 0.6310 $40.19 ........... $8.04
trial.
G0294.............. Non-cov proc, clinical .................. X................. 0340 0.6310 $40.19 ........... $8.04
trial.
G0295.............. Electromagnetic therapy .................. E................. ........... ........... ........... ........... ...........
onc.
G0297.............. Insert single chamber/cd.. CH................ D................. ........... ........... ........... ........... ...........
G0298.............. Insert dual chamber/cd.... CH................ D................. ........... ........... ........... ........... ...........
G0299.............. Inser/repos single CH................ D................. ........... ........... ........... ........... ...........
icd+leads.
[[Page 67134]]
G0300.............. Insert reposit lead CH................ D................. ........... ........... ........... ........... ...........
dual+gen.
G0302.............. Pre-op service LVRS CH................ S................. 0209 11.2822 $718.61 $268.73 $143.72
complete.
G0303.............. Pre-op service LVRS 10- CH................ S................. 0209 11.2822 $718.61 $268.73 $143.72
15dos.
G0304.............. Pre-op service LVRS 1-9 CH................ S................. 0213 2.2980 $146.37 $53.58 $29.27
dos.
G0305.............. Post op service LVRS min 6 CH................ S................. 0213 2.2980 $146.37 $53.58 $29.27
G0306.............. CBC/diffwbc w/o platelet.. .................. A................. ........... ........... ........... ........... ...........
G0307.............. CBC without platelet...... .................. A................. ........... ........... ........... ........... ...........
G0308.............. ESRD related svc 4+mo < .................. B................. ........... ........... ........... ........... ...........
2yrs.
G0309.............. ESRD related svc 2-3mo .................. B................. ........... ........... ........... ........... ...........
<2yrs.
G0310.............. ESRD related svc 1 vst .................. B................. ........... ........... ........... ........... ...........
<2yrs.
G0311.............. ESRD related svs 4+mo 2- .................. B................. ........... ........... ........... ........... ...........
11yr.
G0312.............. ESRD relate svs 2-3 mo 2- .................. B................. ........... ........... ........... ........... ...........
11y.
G0313.............. ESRD related svs 1 mon 2- .................. B................. ........... ........... ........... ........... ...........
11y.
G0314.............. ESRD related svs 4+ mo 12- .................. B................. ........... ........... ........... ........... ...........
19.
G0315.............. ESRD related svs 2-3mo/12- .................. B................. ........... ........... ........... ........... ...........
19.
G0316.............. ESRD related svs 1vis/12- .................. B................. ........... ........... ........... ........... ...........
19y.
G0317.............. ESRD related svs 4+mo .................. B................. ........... ........... ........... ........... ...........
20+yrs.
G0318.............. ESRD related svs 2-3 mo .................. B................. ........... ........... ........... ........... ...........
20+y.
G0319.............. ESRD related svs 1visit .................. B................. ........... ........... ........... ........... ...........
20+y.
G0320.............. ESD related svs home undr .................. B................. ........... ........... ........... ........... ...........
2.
G0321.............. ESRDrelatedsvs home mo 2- .................. B................. ........... ........... ........... ........... ...........
11y.
G0322.............. ESRD related svs hom mo12- .................. B................. ........... ........... ........... ........... ...........
19.
G0323.............. ESRD related svs home mo .................. B................. ........... ........... ........... ........... ...........
20+.
G0324.............. ESRD relate svs home/dy .................. B................. ........... ........... ........... ........... ...........
<2yr.
G0325.............. ESRD relate home/day/ 2- .................. B................. ........... ........... ........... ........... ...........
11yr.
G0326.............. ESRD relate home/dy 12- .................. B................. ........... ........... ........... ........... ...........
19yr.
G0327.............. ESRD relate home/dy 20+yrs .................. B................. ........... ........... ........... ........... ...........
G0328.............. Fecal blood scrn .................. A................. ........... ........... ........... ........... ...........
immunoassay.
G0329.............. Electromagntic tx for .................. A................. ........... ........... ........... ........... ...........
ulcers.
G0332.............. Preadmin IV immunoglobulin CH................ S................. 0430 0.5921 $37.71 ........... $7.54
G0333.............. Dispense fee initial 30 .................. M................. ........... ........... ........... ........... ...........
day.
G0337.............. Hospice evaluation .................. B................. ........... ........... ........... ........... ...........
preelecti.
G0339.............. Robot lin-radsurg com, .................. S................. 0067 61.6965 $3,929.70 ........... $785.94
first.
G0340.............. Robt lin-radsurg fractx 2- .................. S................. 0066 45.0693 $2,870.64 ........... $574.13
5.
G0341.............. Percutaneous islet .................. C................. ........... ........... ........... ........... ...........
celltrans.
G0342.............. Laparoscopy islet cell .................. C................. ........... ........... ........... ........... ...........
trans.
G0343.............. Laparotomy islet cell .................. C................. ........... ........... ........... ........... ...........
transp.
G0344.............. Initial preventive exam... .................. V................. 0605 0.9964 $63.46 ........... $12.69
G0364.............. Bone marrow aspirate .................. T................. 0002 1.1097 $70.68 ........... $14.14
&biopsy.
G0365.............. Vessel mapping hemo access .................. S................. 0267 2.3792 $151.54 $60.50 $30.31
G0366.............. EKG for initial prevent .................. B................. ........... ........... ........... ........... ...........
exam.
G0367.............. EKG tracing for initial .................. S................. 0099 0.3892 $24.79 ........... $4.96
prev.
G0368.............. EKG interpret & report .................. M................. ........... ........... ........... ........... ...........
preve.
G0372.............. MD service required for .................. M................. ........... ........... ........... ........... ...........
PMD.
G0375.............. Smoke/tobacco counselng 3- CH................ D................. ........... ........... ........... ........... ...........
10.
G0376.............. Smoke/tobacco counseling CH................ D................. ........... ........... ........... ........... ...........
>10.
G0377.............. Administra Part D vaccine. .................. S................. 0437 0.3945 $25.13 ........... $5.03
G0378.............. Hospital observation per CH................ N................. ........... ........... ........... ........... ...........
hr.
G0379.............. Direct admit hospital CH................ Q................. 0604 0.8388 $53.43 ........... $10.69
observ.
G0380.............. Lev 1 hosp type B ED visit .................. V................. 0604 0.8388 $53.43 ........... $10.69
G0381.............. Lev 2 hosp type B ED visit .................. V................. 0605 0.9964 $63.46 ........... $12.69
G0382.............. Lev 3 hosp type B ED visit .................. V................. 0606 1.3226 $84.24 ........... $16.85
G0383.............. Lev 4 hosp type B ED visit .................. V................. 0607 1.6604 $105.76 ........... $21.15
G0384.............. Lev 5 hosp type B ED visit .................. V................. 0608 2.1740 $138.47 ........... $27.69
G0389.............. Ultrasound exam AAA screen .................. S................. 0266 1.5094 $96.14 $37.80 $19.23
G0390.............. Trauma Respons w/hosp .................. S................. 0618 5.1854 $330.28 $132.11 $66.06
criti.
G0392.............. AV fistula or graft CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
arterial.
G0393.............. AV fistula or graft venous CH................ T................. 0083 45.3845 $2,890.72 ........... $578.14
G0394.............. Blood occult .................. A................. ........... ........... ........... ........... ...........
test,colorectal.
G0396.............. Alcohol/subs interv 15- NI................ S................. 0432 0.3128 $19.92 ........... $3.98
30mn.
G0397.............. Alcohol/subs interv >30 NI................ S................. 0432 0.3128 $19.92 ........... $3.98
min.
G3001.............. Admin + supply, .................. S................. 0442 27.4298 $1,747.11 ........... $349.42
tositumomab.
G8006.............. AMI pt recd aspirin at .................. M................. ........... ........... ........... ........... ...........
arriv.
G8007.............. AMI pt did not receiv .................. M................. ........... ........... ........... ........... ...........
aspiri.
G8008.............. AMI pt ineligible for .................. M................. ........... ........... ........... ........... ...........
aspiri.
G8009.............. AMI pt recd Bblock at arr. .................. M................. ........... ........... ........... ........... ...........
G8010.............. AMI pt did not rec bblock. .................. M................. ........... ........... ........... ........... ...........
G8011.............. AMI pt inelig Bbloc at .................. M................. ........... ........... ........... ........... ...........
arriv.
G8012.............. Pneum pt recv antibiotic 4 .................. M................. ........... ........... ........... ........... ...........
h.
G8013.............. Pneum pt w/o antibiotic 4 .................. M................. ........... ........... ........... ........... ...........
hr.
G8014.............. Pneum pt not elig .................. M................. ........... ........... ........... ........... ...........
antibiotic.
G8015.............. Diabetic pt w/ HBA1c>9%... .................. M................. ........... ........... ........... ........... ...........
G8016.............. Diabetic pt w/ HBA1c= 100mg/ .................. M................. ........... ........... ........... ........... ...........
dl.
G8020.............. Diab pt w/LDL< 100mg/dl... .................. M................. ........... ........... ........... ........... ...........
G8021.............. Diab pt inelig for LDL .................. M................. ........... ........... ........... ........... ...........
meas.
G8022.............. Care not provided for LDL. .................. M................. ........... ........... ........... ........... ...........
G8023.............. DM pt w BP>=140/80........ .................. M................. ........... ........... ........... ........... ...........
[[Page 67135]]
G8024.............. Diabetic pt wBP<140/80.... .................. M................. ........... ........... ........... ........... ...........
G8025.............. Diabetic pt inelig for BP .................. M................. ........... ........... ........... ........... ...........
me.
G8026.............. Diabet pt w no care re BP .................. M................. ........... ........... ........... ........... ...........
me.
G8027.............. HF p w/LVSD on ACE-I/ARB.. .................. M................. ........... ........... ........... ........... ...........
G8028.............. HF pt w/LVSD not on ACE-I/ .................. M................. ........... ........... ........... ........... ...........
AR.
G8029.............. HF pt not elig for ACE-I/ .................. M................. ........... ........... ........... ........... ...........
ARB.
G8030.............. HF pt w/LVSD on Bblocker.. .................. M................. ........... ........... ........... ........... ...........
G8031.............. HF pt w/LVSD not on .................. M................. ........... ........... ........... ........... ...........
Bblocker.
G8032.............. HF pt not elig for .................. M................. ........... ........... ........... ........... ...........
Bblocker.
G8033.............. PMI-CAD pt on Bblocker.... .................. M................. ........... ........... ........... ........... ...........
G8034.............. PMI-CAD pt not on Bblocker .................. M................. ........... ........... ........... ........... ...........
G8035.............. PMI-CAD pt inelig Bblocker .................. M................. ........... ........... ........... ........... ...........
G8036.............. AMI-CAD pt doc on .................. M................. ........... ........... ........... ........... ...........
antiplatel.
G8037.............. AMI-CAD pt not docu on .................. M................. ........... ........... ........... ........... ...........
antip.
G8038.............. AMI-CAD inelig antiplate .................. M................. ........... ........... ........... ........... ...........
mea.
G8039.............. CAD pt w/LDL>100mg/dl..... .................. M................. ........... ........... ........... ........... ...........
G8040.............. CAD pt w/LDL=65%.
G8076.............. ESRD pt w/ dialy of .................. M................. ........... ........... ........... ........... ...........
URR<65%.
G8077.............. ESRD pt not elig for URR/ .................. M................. ........... ........... ........... ........... ...........
KtV.
G8078.............. ESRD pt w/Hct>or=33....... .................. M................. ........... ........... ........... ........... ...........
G8079.............. ESRD pt w/Hct<33.......... .................. M................. ........... ........... ........... ........... ...........
G8080.............. ESRD pt inelig for HCT/Hgb .................. M................. ........... ........... ........... ........... ...........
G8081.............. ESRD pt w/ auto AV fistula .................. M................. ........... ........... ........... ........... ...........
G8082.............. ESRD pt w other fistula... .................. M................. ........... ........... ........... ........... ...........
G8085.............. ESRD PT inelig auto AV .................. M................. ........... ........... ........... ........... ...........
FISTU.
G8093.............. COPD pt rec smoking cessat .................. M................. ........... ........... ........... ........... ...........
G8094.............. COPD pt w/o smoke cessat .................. M................. ........... ........... ........... ........... ...........
int.
G8099.............. Osteopo pt given Ca+VitD .................. M................. ........... ........... ........... ........... ...........
sup.
G8100.............. Osteop pt inelig for .................. M................. ........... ........... ........... ........... ...........
Ca+VitD.
G8103.............. New dx osteo pt w/ .................. M................. ........... ........... ........... ........... ...........
antiresorp.
G8104.............. Osteo pt inelig for .................. M................. ........... ........... ........... ........... ...........
antireso.
G8106.............. Bone dens meas test perf.. .................. M................. ........... ........... ........... ........... ...........
G8107.............. Bone dens meas test inelig .................. M................. ........... ........... ........... ........... ...........
G8108.............. Pt receiv influenza vacc.. .................. M................. ........... ........... ........... ........... ...........
G8109.............. Pt w/o influenza vacc..... .................. M................. ........... ........... ........... ........... ...........
G8110.............. Pt inelig for influenza .................. M................. ........... ........... ........... ........... ...........
vacc.
G8111.............. Pt receiv mammogram....... .................. M................. ........... ........... ........... ........... ...........
G8112.............. Pt not doc mammogram...... .................. M................. ........... ........... ........... ........... ...........
G8113.............. Pt ineligible mammography. .................. M................. ........... ........... ........... ........... ...........
G8114.............. Care not provided for .................. M................. ........... ........... ........... ........... ...........
mamogr.
G8115.............. Pt receiv pneumo vacc..... .................. M................. ........... ........... ........... ........... ...........
G8116.............. Pt did not rec pneumo vacc .................. M................. ........... ........... ........... ........... ...........
G8117.............. Pt was inelig for pneumo .................. M................. ........... ........... ........... ........... ...........
vac.
G8126.............. Pt treat w/ .................. M................. ........... ........... ........... ........... ...........
antidepress12wks.
G8127.............. Pt not treat w/ .................. M................. ........... ........... ........... ........... ...........
antidepres12w.
G8128.............. Pt inelig for antidepres .................. M................. ........... ........... ........... ........... ...........
med.
G8129.............. Pt treat w/antidepres for .................. M................. ........... ........... ........... ........... ...........
6m.
G8130.............. Pt not treat w/antidepres .................. M................. ........... ........... ........... ........... ...........
6m.
G8131.............. Pt inelig for antidepres .................. M................. ........... ........... ........... ........... ...........
med.
G8152.............. Pt w/AB 1 hr prior to .................. M................. ........... ........... ........... ........... ...........
incisi.
G8153.............. Pt not doc for AB 1 hr .................. M................. ........... ........... ........... ........... ...........
prior.
G8154.............. Pt ineligi for AB therapy. .................. M................. ........... ........... ........... ........... ...........
G8155.............. Pt recd thromboemb .................. M................. ........... ........... ........... ........... ...........
prophylax.
G8156.............. Pt did not rec thromboembo .................. M................. ........... ........... ........... ........... ...........
G8157.............. Pt ineligi for thrombolism .................. M................. ........... ........... ........... ........... ...........
G8159.............. Pt w/CABG w/o IMA......... .................. M................. ........... ........... ........... ........... ...........
G8162.............. Iso CABG pt w/o preop .................. M................. ........... ........... ........... ........... ...........
Bblock.
G8164.............. Iso CABG pt w/prolng intub .................. M................. ........... ........... ........... ........... ...........
G8165.............. Iso CABG pt w/o prolng .................. M................. ........... ........... ........... ........... ...........
intub.
G8166.............. Iso CABG req surg rexpo... .................. M................. ........... ........... ........... ........... ...........
G8167.............. Iso CABG w/o surg explo... .................. M................. ........... ........... ........... ........... ...........
G8170.............. CEA/ext bypass pt on .................. M................. ........... ........... ........... ........... ...........
aspirin.
G8171.............. Pt w/carot endarct/ext .................. M................. ........... ........... ........... ........... ...........
bypas.
G8172.............. CEA/ext bypass pt not on .................. M................. ........... ........... ........... ........... ...........
asp.
G8182.............. CAD pt care not prov LDL.. .................. M................. ........... ........... ........... ........... ...........
G8183.............. HF/atrial fib pt on .................. M................. ........... ........... ........... ........... ...........
warfarin.
[[Page 67136]]
G8184.............. HF/atrial fib pt inelig .................. M................. ........... ........... ........... ........... ...........
warf.
G8185.............. Osteoarth pt w/ assess .................. M................. ........... ........... ........... ........... ...........
pain.
G8186.............. Osteoarth pt inelig assess .................. M................. ........... ........... ........... ........... ...........
G8193.............. Antibio not doc prior surg .................. M................. ........... ........... ........... ........... ...........
G8196.............. Antibio not docum prior .................. M................. ........... ........... ........... ........... ...........
surg.
G8200.............. Cefazolin not docum prophy .................. M................. ........... ........... ........... ........... ...........
G8204.............. MD not doc order to d/c .................. M................. ........... ........... ........... ........... ...........
anti.
G8209.............. Clinician did not doc..... .................. M................. ........... ........... ........... ........... ...........
G8214.............. Clini not doc order VTE... .................. M................. ........... ........... ........... ........... ...........
G8217.............. Pt not received DVT proph. .................. M................. ........... ........... ........... ........... ...........
G8219.............. Received DVT proph day 2.. .................. M................. ........... ........... ........... ........... ...........
G8220.............. Pt not rec DVT proph day 2 .................. M................. ........... ........... ........... ........... ...........
G8221.............. Pt inelig for DVT proph... .................. M................. ........... ........... ........... ........... ...........
G8223.............. Pt not doc for presc .................. M................. ........... ........... ........... ........... ...........
antipla.
G8226.............. Pt no prescr anticoa at D/ .................. M................. ........... ........... ........... ........... ...........
C.
G8231.............. Pt not doc for admin t-PA. .................. M................. ........... ........... ........... ........... ...........
G8234.............. Pt not doc dysphagia .................. M................. ........... ........... ........... ........... ...........
screen.
G8238.............. Pt not doc to rec rehab .................. M................. ........... ........... ........... ........... ...........
serv.
G8240.............. Inter carotid stenosis30- .................. M................. ........... ........... ........... ........... ...........
99%.
G8243.............. Pt not doc MRI/CT w/o .................. M................. ........... ........... ........... ........... ...........
lesion.
G8246.............. Pt inelig hx w new/chg .................. M................. ........... ........... ........... ........... ...........
mole.
G8248.............. Pt w/one alarm symp not .................. M................. ........... ........... ........... ........... ...........
doc.
G8251.............. Pt not doc w/Barretts, .................. M................. ........... ........... ........... ........... ...........
endo.
G8254.............. Pt w/no doc order for .................. M................. ........... ........... ........... ........... ...........
barium.
G8257.............. Pt not doc rev meds D/C... .................. M................. ........... ........... ........... ........... ...........
G8260.............. Pt not doc to have dec .................. M................. ........... ........... ........... ........... ...........
maker.
G8263.............. Pt not doc assess urinary .................. M................. ........... ........... ........... ........... ...........
in.
G8266.............. Pt not doc charc urin .................. M................. ........... ........... ........... ........... ...........
incon.
G8268.............. Pt not doc rec care urin .................. M................. ........... ........... ........... ........... ...........
inc.
G8271.............. Pt no doc screen fall..... .................. M................. ........... ........... ........... ........... ...........
G8274.............. Clini not doc pres/abs .................. M................. ........... ........... ........... ........... ...........
alarm.
G8276.............. Pt not doc mole change.... .................. M................. ........... ........... ........... ........... ...........
G8279.............. Pt not doc rec PE......... .................. M................. ........... ........... ........... ........... ...........
G8282.............. Pt not doc to rec couns... .................. M................. ........... ........... ........... ........... ...........
G8285.............. Pt did not rec pres osteo. .................. M................. ........... ........... ........... ........... ...........
G8289.............. Pt not doc rec Ca/Vit D... .................. M................. ........... ........... ........... ........... ...........
G8293.............. COPD pt w/o spir results.. .................. M................. ........... ........... ........... ........... ...........
G8296.............. COPD pt not doc bronch .................. M................. ........... ........... ........... ........... ...........
ther.
G8298.............. Pt doc optic nerve eval... .................. M................. ........... ........... ........... ........... ...........
G8299.............. Pt not doc optic nerv eval .................. M................. ........... ........... ........... ........... ...........
G8302.............. Pt doc w/ target IOP...... .................. M................. ........... ........... ........... ........... ...........
G8303.............. Pt not doc w/ IOP......... .................. M................. ........... ........... ........... ........... ...........
G8304.............. Clin doc pt inelig IOP.... .................. M................. ........... ........... ........... ........... ...........
G8305.............. Clin not prov care POAG... .................. M................. ........... ........... ........... ........... ...........
G8306.............. POAG w/ IOP rec care plan. .................. M................. ........... ........... ........... ........... ...........
G8307.............. POAG w/ IOP no care plan.. .................. M................. ........... ........... ........... ........... ...........
G8308.............. POAG w/ IOP not doc plan.. .................. M................. ........... ........... ........... ........... ...........
G8310.............. Pt not doc rec antiox..... .................. M................. ........... ........... ........... ........... ...........
G8314.............. Pt not doc to rec mac exam .................. M................. ........... ........... ........... ........... ...........
G8318.............. Pt doc not have visual .................. M................. ........... ........... ........... ........... ...........
func.
G8322.............. Pt not doc pre axial leng. .................. M................. ........... ........... ........... ........... ...........
G8326.............. Pt not doc rec fundus exam .................. M................. ........... ........... ........... ........... ...........
G8330.............. Pt not doc rec dilated mac .................. M................. ........... ........... ........... ........... ...........
G8334.............. Doc of macular not giv MD. .................. M................. ........... ........... ........... ........... ...........
G8338.............. Clin not doc pt test osteo .................. M................. ........... ........... ........... ........... ...........
G8341.............. Pt not doc for DEXA....... .................. M................. ........... ........... ........... ........... ...........
G8345.............. Pt not doc have DEXA...... .................. M................. ........... ........... ........... ........... ...........
G8351.............. Pt not doc ECG............ .................. M................. ........... ........... ........... ........... ...........
G8354.............. Pt not rec aspirin prior .................. M................. ........... ........... ........... ........... ...........
ER.
G8357.............. Pt not doc to have ECG.... .................. M................. ........... ........... ........... ........... ...........
G8360.............. Pt not doc vital signs .................. M................. ........... ........... ........... ........... ...........
recor.
G8362.............. Pt not doc 02 SAT assess.. .................. M................. ........... ........... ........... ........... ...........
G8365.............. Pt not doc mental status.. .................. M................. ........... ........... ........... ........... ...........
G8367.............. Pt not doc have empiric AB .................. M................. ........... ........... ........... ........... ...........
G8370.............. Asthma pt w survey not .................. M................. ........... ........... ........... ........... ...........
docum.
G8371.............. Chemother not rec stg3 .................. M................. ........... ........... ........... ........... ...........
colon.
G8372.............. Chemother rec stg 3 colon .................. M................. ........... ........... ........... ........... ...........
ca.
G8373.............. Chemo plan docum prior .................. M................. ........... ........... ........... ........... ...........
chemo.
G8374.............. Chemo plan not doc prior .................. M................. ........... ........... ........... ........... ...........
che.
G8375.............. CLL pt w/o doc flow .................. M................. ........... ........... ........... ........... ...........
cytometr.
G8376.............. Brst ca pt inelig .................. M................. ........... ........... ........... ........... ...........
tamoxifen.
G8377.............. MD doc colon ca pt inelig .................. M................. ........... ........... ........... ........... ...........
ch.
G8378.............. MD doc pt inelig rad .................. M................. ........... ........... ........... ........... ...........
therapy.
G8379.............. Radiat tx recom doc12mo ov .................. M................. ........... ........... ........... ........... ...........
G8380.............. Pt w stgIC-3Brst ca w/o .................. M................. ........... ........... ........... ........... ...........
tam.
G8381.............. Pt w stgIC-3Brst ca rec .................. M................. ........... ........... ........... ........... ...........
tam.
G8382.............. MM pt w/o doc IV .................. M................. ........... ........... ........... ........... ...........
bisphophon.
G8383.............. Radiation rec not doc 12 .................. M................. ........... ........... ........... ........... ...........
mo.
G8384.............. MDS pt w/o base cytogen .................. M................. ........... ........... ........... ........... ...........
test.
G8385.............. Diab pt w nodoc Hgb A1c .................. M................. ........... ........... ........... ........... ...........
12m.
[[Page 67137]]
G8386.............. Diab pt w nodoc LDL 12m... .................. M................. ........... ........... ........... ........... ...........
G8387.............. ESRD pt w Hct/Hgb not .................. M................. ........... ........... ........... ........... ...........
docume.
G8388.............. ESRD pt w URR/Ktv not doc .................. M................. ........... ........... ........... ........... ...........
el.
G8389.............. MDS pt no doc Fe prior EPO .................. M................. ........... ........... ........... ........... ...........
G8390.............. Diabetic w/o document BP .................. M................. ........... ........... ........... ........... ...........
12m.
G8391.............. Pt w asthma no doc med or .................. M................. ........... ........... ........... ........... ...........
tx.
G8395.............. LVEF>=40% doc normal or NI................ M................. ........... ........... ........... ........... ...........
mild.
G8396.............. LVEF not performed........ NI................ M................. ........... ........... ........... ........... ...........
G8397.............. Dil macula/fundus exam/w NI................ M................. ........... ........... ........... ........... ...........
doc.
G8398.............. Dil macular/fundus not NI................ M................. ........... ........... ........... ........... ...........
perfo.
G8399.............. Pt w/DXA document or order NI................ M................. ........... ........... ........... ........... ...........
G8400.............. Pt w/DXA no document or NI................ M................. ........... ........... ........... ........... ...........
orde.
G8401.............. Pt inelig osteo screen NI................ M................. ........... ........... ........... ........... ...........
measu.
G8402.............. Smoke preven interven NI................ M................. ........... ........... ........... ........... ...........
counse.
G8403.............. Smoke preven nocounsel.... NI................ M................. ........... ........... ........... ........... ...........
G8404.............. Low extemity neur exam NI................ M................. ........... ........... ........... ........... ...........
docum.
G8405.............. Low extemity neur not NI................ M................. ........... ........... ........... ........... ...........
perfor.
G8406.............. Pt inelig lower extrem NI................ M................. ........... ........... ........... ........... ...........
neuro.
G8407.............. ABI documented............ NI................ M................. ........... ........... ........... ........... ...........
G8408.............. ABI not documented........ NI................ M................. ........... ........... ........... ........... ...........
G8409.............. Pt inelig for ABI measure. NI................ M................. ........... ........... ........... ........... ...........
G8410.............. Eval on foot documented... NI................ M................. ........... ........... ........... ........... ...........
G8415.............. Eval on foot not performed NI................ M................. ........... ........... ........... ........... ...........
G8416.............. Pt inelig footwear NI................ M................. ........... ........... ........... ........... ...........
evaluatio.
G8417.............. BMI >=30 calcuate w/ NI................ M................. ........... ........... ........... ........... ...........
followup.
G8418.............. BMI < 22 calcuate w/ NI................ M................. ........... ........... ........... ........... ...........
followup.
G8419.............. BMI>=30or<22 cal no NI................ M................. ........... ........... ........... ........... ...........
followup.
G8420.............. BMI<30 and >=22 calc & NI................ M................. ........... ........... ........... ........... ...........
docu.
G8421.............. BMI not calculated........ NI................ M................. ........... ........... ........... ........... ...........
G8422.............. Pt inelig BMI calculation. NI................ M................. ........... ........... ........... ........... ...........
G8423.............. Pt screen flu vac & NI................ M................. ........... ........... ........... ........... ...........
counsel.
G8424.............. Flu vaccine not screen.... NI................ M................. ........... ........... ........... ........... ...........
G8425.............. Flu vaccine screen not NI................ M................. ........... ........... ........... ........... ...........
curre.
G8426.............. Pt not approp screen & NI................ M................. ........... ........... ........... ........... ...........
counc.
G8427.............. Doc meds verified w/pt or NI................ M................. ........... ........... ........... ........... ...........
re.
G8428.............. Meds document w/o verifica NI................ M................. ........... ........... ........... ........... ...........
G8429.............. Incomplete doc pt on meds. NI................ M................. ........... ........... ........... ........... ...........
G8430.............. Pt inelig med check....... NI................ M................. ........... ........... ........... ........... ...........
G8431.............. Clin depression screen doc NI................ M................. ........... ........... ........... ........... ...........
G8432.............. Clin depression screen not NI................ M................. ........... ........... ........... ........... ...........
d.
G8433.............. Pt inelig for depression NI................ M................. ........... ........... ........... ........... ...........
scr.
G8434.............. Cognitive impairment NI................ M................. ........... ........... ........... ........... ...........
screen.
G8435.............. Cognitive screen not NI................ M................. ........... ........... ........... ........... ...........
documen.
G8436.............. Pt inelig for cognitive NI................ M................. ........... ........... ........... ........... ...........
impa.
G8437.............. Tx plan develop & document NI................ M................. ........... ........... ........... ........... ...........
G8438.............. Tx plan develop & not NI................ M................. ........... ........... ........... ........... ...........
docum.
G8439.............. Pt inelig for co-develp tx NI................ M................. ........... ........... ........... ........... ...........
p.
G8440.............. Pain assessment document.. NI................ M................. ........... ........... ........... ........... ...........
G8441.............. No document of pain assess NI................ M................. ........... ........... ........... ........... ...........
G8442.............. Pt inelig pain assessment. NI................ M................. ........... ........... ........... ........... ...........
G8443.............. Prescription by E-Prescrib NI................ M................. ........... ........... ........... ........... ...........
s.
G8445.............. Prescrip not gen at NI................ M................. ........... ........... ........... ........... ...........
encounte.
G8446.............. Some prescrib handwritten NI................ M................. ........... ........... ........... ........... ...........
or.
G8447.............. Pt visit doc using CCHIT NI................ M................. ........... ........... ........... ........... ...........
cer.
G8448.............. Pt visit docum w/non-CCHIT NI................ M................. ........... ........... ........... ........... ...........
c.
G8449.............. Pt not doc w/EMR due to NI................ M................. ........... ........... ........... ........... ...........
syst.
G8450.............. Beta-bloc rx pt w/abn lvef NI................ M................. ........... ........... ........... ........... ...........
G8451.............. Pt w/abn lvef inelig b- NI................ M................. ........... ........... ........... ........... ...........
bloc.
G8452.............. Pt w/abn lvef b-bloc no rx NI................ M................. ........... ........... ........... ........... ...........
G8453.............. Tob use cess int counsel.. NI................ M................. ........... ........... ........... ........... ...........
G8454.............. Tob use cess int no NI................ M................. ........... ........... ........... ........... ...........
counsel.
G8455.............. Current tobacco smoker.... NI................ M................. ........... ........... ........... ........... ...........
G8456.............. Smokeless tobacco user.... NI................ M................. ........... ........... ........... ........... ...........
G8457.............. Tobacco non-user.......... NI................ M................. ........... ........... ........... ........... ...........
G8458.............. Pt inelig geno no antvir NI................ M................. ........... ........... ........... ........... ...........
tx.
G8459.............. Doc pt rec antivir treat.. NI................ M................. ........... ........... ........... ........... ...........
G8460.............. Pt inelig RNA no antvir tx NI................ M................. ........... ........... ........... ........... ...........
G8461.............. Pt rec antivir treat hep c NI................ M................. ........... ........... ........... ........... ...........
G8462.............. Pt inelig couns no antvir NI................ M................. ........... ........... ........... ........... ...........
tx.
G8463.............. Pt rec antiviral treat doc NI................ M................. ........... ........... ........... ........... ...........
G8464.............. Pt inelig; lo to no dter NI................ M................. ........... ........... ........... ........... ...........
rsk.
G8465.............. High risk recurrence pro NI................ M................. ........... ........... ........... ........... ...........
ca.
G8466.............. Pt inelig suic; MDD remis. NI................ M................. ........... ........... ........... ........... ...........
G8467.............. New dx init/rec episode NI................ M................. ........... ........... ........... ........... ...........
MDD.
G8468.............. ACE/ARB rx pt w/abn lvef.. NI................ M................. ........... ........... ........... ........... ...........
G8469.............. Pt w/abn lvef inelig ACE/ NI................ M................. ........... ........... ........... ........... ...........
ARB.
G8470.............. Pt w/ normal lvef......... NI................ M................. ........... ........... ........... ........... ...........
G8471.............. LVEF not performed/doc.... NI................ M................. ........... ........... ........... ........... ...........
G8472.............. ACE/ARB no rx pt w/abn NI................ M................. ........... ........... ........... ........... ...........
lvef.
G8473.............. ACE/ARB thxpy rx'd........ NI................ M................. ........... ........... ........... ........... ...........
[[Page 67138]]
G8474.............. ACE/ARB not rx'd; doc reas NI................ M................. ........... ........... ........... ........... ...........
G8475.............. ACE/ARB thxpy not rx'd.... NI................ M................. ........... ........... ........... ........... ...........
G8476.............. BP sys <130 and dias <80.. NI................ M................. ........... ........... ........... ........... ...........
G8477.............. BP sys>=130 and/or dias NI................ M................. ........... ........... ........... ........... ...........
>=80.
G8478.............. BP not performed/doc...... NI................ M................. ........... ........... ........... ........... ...........
G8479.............. MD rx'd ACE/ARB thxpy..... NI................ M................. ........... ........... ........... ........... ...........
G8480.............. Pt inelig ACE/ARB thxpy... NI................ M................. ........... ........... ........... ........... ...........
G8481.............. MD not rx'd ACE/ARB thxpy. NI................ M................. ........... ........... ........... ........... ...........
G8482.............. Flu immunize order/admin.. NI................ M................. ........... ........... ........... ........... ...........
G8483.............. Flu imm no ord/admin doc NI................ M................. ........... ........... ........... ........... ...........
rea.
G8484.............. Flu immunize no order/ NI................ M................. ........... ........... ........... ........... ...........
admin.
G9001.............. MCCD, initial rate........ .................. B................. ........... ........... ........... ........... ...........
G9002.............. MCCD,maintenance rate..... .................. B................. ........... ........... ........... ........... ...........
G9003.............. MCCD, risk adj hi, initial .................. B................. ........... ........... ........... ........... ...........
G9004.............. MCCD, risk adj lo, initial .................. B................. ........... ........... ........... ........... ...........
G9005.............. MCCD, risk adj, .................. B................. ........... ........... ........... ........... ...........
maintenance.
G9006.............. MCCD, Home monitoring..... .................. B................. ........... ........... ........... ........... ...........
G9007.............. MCCD, sch team conf....... .................. B................. ........... ........... ........... ........... ...........
G9008.............. Mccd,phys coor-care .................. B................. ........... ........... ........... ........... ...........
ovrsght.
G9009.............. MCCD, risk adj, level 3... .................. B................. ........... ........... ........... ........... ...........
G9010.............. MCCD, risk adj, level 4... .................. B................. ........... ........... ........... ........... ...........
G9011.............. MCCD, risk adj, level 5... .................. B................. ........... ........... ........... ........... ...........
G9012.............. Other Specified Case Mgmt. .................. B................. ........... ........... ........... ........... ...........
G9013.............. ESRD demo bundle level I.. .................. E................. ........... ........... ........... ........... ...........
G9014.............. ESRD demo bundle-level II. .................. E................. ........... ........... ........... ........... ...........
G9016.............. Demo-smoking cessation .................. E................. ........... ........... ........... ........... ...........
coun.
G9017.............. Amantadine HCL 100mg oral. .................. A................. ........... ........... ........... ........... ...........
G9018.............. Zanamivir,inhalation pwd .................. A................. ........... ........... ........... ........... ...........
10m.
G9019.............. Oseltamivir phosphate 75mg .................. A................. ........... ........... ........... ........... ...........
G9020.............. Rimantadine HCL 100mg oral .................. A................. ........... ........... ........... ........... ...........
G9033.............. Amantadine HCL oral brand. .................. A................. ........... ........... ........... ........... ...........
G9034.............. Zanamivir, inh pwdr, brand .................. A................. ........... ........... ........... ........... ...........
G9035.............. Oseltamivir phosp, brand.. .................. A................. ........... ........... ........... ........... ...........
G9036.............. Rimantadine HCL, brand.... .................. A................. ........... ........... ........... ........... ...........
G9041.............. Low vision rehab .................. A................. ........... ........... ........... ........... ...........
occupationa.
G9042.............. Low vision rehab orient/ .................. A................. ........... ........... ........... ........... ...........
mobi.
G9043.............. Low vision lowvision .................. A................. ........... ........... ........... ........... ...........
therapi.
G9044.............. Low vision rehabilate .................. A................. ........... ........... ........... ........... ...........
teache.
G9050.............. Oncology work-up .................. E................. ........... ........... ........... ........... ...........
evaluation.
G9051.............. Oncology tx decision-mgmt. .................. E................. ........... ........... ........... ........... ...........
G9052.............. Onc surveillance for .................. E................. ........... ........... ........... ........... ...........
disease.
G9053.............. Onc expectant management .................. E................. ........... ........... ........... ........... ...........
pt.
G9054.............. Onc supervision palliative .................. E................. ........... ........... ........... ........... ...........
G9055.............. Onc visit unspecified NOS. .................. E................. ........... ........... ........... ........... ...........
G9056.............. Onc prac mgmt adheres .................. E................. ........... ........... ........... ........... ...........
guide.
G9057.............. Onc pract mgmt differs .................. E................. ........... ........... ........... ........... ...........
trial.
G9058.............. Onc prac mgmt disagree w/ .................. E................. ........... ........... ........... ........... ...........
gui.
G9059.............. Onc prac mgmt pt opt .................. E................. ........... ........... ........... ........... ...........
alterna.
G9060.............. Onc prac mgmt dif pt .................. E................. ........... ........... ........... ........... ...........
comorb.
G9061.............. Onc prac cond noadd by .................. E................. ........... ........... ........... ........... ...........
guide.
G9062.............. Onc prac guide differs nos .................. E................. ........... ........... ........... ........... ...........
G9063.............. Onc dx nsclc stgI no .................. M................. ........... ........... ........... ........... ...........
progres.
G9064.............. Onc dx nsclc stg2 no .................. M................. ........... ........... ........... ........... ...........
progres.
G9065.............. Onc dx nsclc stg3A no .................. M................. ........... ........... ........... ........... ...........
progre.
G9066.............. Onc dx nsclc stg3B-4 .................. M................. ........... ........... ........... ........... ...........
metasta.
G9067.............. Onc dx nsclc dx unknown .................. M................. ........... ........... ........... ........... ...........
nos.
G9068.............. Onc dx sclc/nsclc limited. .................. M................. ........... ........... ........... ........... ...........
G9069.............. Onc dx sclc/nsclc ext at .................. M................. ........... ........... ........... ........... ...........
dx.
G9070.............. Onc dx sclc/nsclc ext .................. M................. ........... ........... ........... ........... ...........
unknwn.
G9071.............. Onc dx brst stg1-2B .................. M................. ........... ........... ........... ........... ...........
HR,nopro.
G9072.............. Onc dx brst stg1-2 .................. M................. ........... ........... ........... ........... ...........
noprogres.
G9073.............. Onc dx brst stg3-HR, no .................. M................. ........... ........... ........... ........... ...........
pro.
G9074.............. Onc dx brst stg3- .................. M................. ........... ........... ........... ........... ...........
noprogress.
G9075.............. Onc dx brst metastic/ .................. M................. ........... ........... ........... ........... ...........
recur.
G9077.............. Onc dx prostate T1no .................. M................. ........... ........... ........... ........... ...........
progres.
G9078.............. Onc dx prostate T2no .................. M................. ........... ........... ........... ........... ...........
progres.
G9079.............. Onc dx prostate T3b- .................. M................. ........... ........... ........... ........... ...........
T4noprog.
G9080.............. Onc dx prostate w/rise PSA .................. M................. ........... ........... ........... ........... ...........
G9083.............. Onc dx prostate unknwn nos .................. M................. ........... ........... ........... ........... ...........
G9084.............. Onc dx colon t1-3,n1-2,no .................. M................. ........... ........... ........... ........... ...........
pr.
G9085.............. Onc dx colon T4, N0 w/o .................. M................. ........... ........... ........... ........... ...........
prog.
G9086.............. Onc dx colon T1-4 no dx .................. M................. ........... ........... ........... ........... ...........
prog.
G9087.............. Onc dx colon metas evid dx .................. M................. ........... ........... ........... ........... ...........
G9088.............. Onc dx colon metas noevid .................. M................. ........... ........... ........... ........... ...........
dx.
G9089.............. Onc dx colon extent .................. M................. ........... ........... ........... ........... ...........
unknown.
G9090.............. Onc dx rectal T1-2 no .................. M................. ........... ........... ........... ........... ...........
progr.
G9091.............. Onc dx rectal T3 N0 no .................. M................. ........... ........... ........... ........... ...........
prog.
G9092.............. Onc dx rectal T1-3,N1- .................. M................. ........... ........... ........... ........... ...........
2noprg.
G9093.............. Onc dx rectal T4,N,M0 no .................. M................. ........... ........... ........... ........... ...........
prg.
G9094.............. Onc dx rectal M1 w/mets .................. M................. ........... ........... ........... ........... ...........
prog.
[[Page 67139]]
G9095.............. Onc dx rectal extent .................. M................. ........... ........... ........... ........... ...........
unknwn.
G9096.............. Onc dx esophag T1-T3 .................. M................. ........... ........... ........... ........... ...........
noprog.
G9097.............. Onc dx esophageal T4 no .................. M................. ........... ........... ........... ........... ...........
prog.
G9098.............. Onc dx esophageal mets .................. M................. ........... ........... ........... ........... ...........
recur.
G9099.............. Onc dx esophageal unknown. .................. M................. ........... ........... ........... ........... ...........
G9100.............. Onc dx gastric no .................. M................. ........... ........... ........... ........... ...........
recurrence.
G9101.............. Onc dx gastric p R1- .................. M................. ........... ........... ........... ........... ...........
R2noprog.
G9102.............. Onc dx gastric .................. M................. ........... ........... ........... ........... ...........
unresectable.
G9103.............. Onc dx gastric recurrent.. .................. M................. ........... ........... ........... ........... ...........
G9104.............. Onc dx gastric unknown NOS .................. M................. ........... ........... ........... ........... ...........
G9105.............. Onc dx pancreatc p R0 res .................. M................. ........... ........... ........... ........... ...........
no.
G9106.............. Onc dx pancreatc p R1/R2 .................. M................. ........... ........... ........... ........... ...........
no.
G9107.............. Onc dx pancreatic .................. M................. ........... ........... ........... ........... ...........
unresectab.
G9108.............. Onc dx pancreatic unknwn .................. M................. ........... ........... ........... ........... ...........
NOS.
G9109.............. Onc dx head/neck T1-T2no .................. M................. ........... ........... ........... ........... ...........
prg.
G9110.............. Onc dx head/neck T3-4 .................. M................. ........... ........... ........... ........... ...........
noprog.
G9111.............. Onc dx head/neck M1 mets .................. M................. ........... ........... ........... ........... ...........
rec.
G9112.............. Onc dx head/neck ext .................. M................. ........... ........... ........... ........... ...........
unknown.
G9113.............. Onc dx ovarian stg1A-B no .................. M................. ........... ........... ........... ........... ...........
pr.
G9114.............. Onc dx ovarian stg1A-B or .................. M................. ........... ........... ........... ........... ...........
2.
G9115.............. Onc dx ovarian stg3/4 .................. M................. ........... ........... ........... ........... ...........
noprog.
G9116.............. Onc dx ovarian recurrence. .................. M................. ........... ........... ........... ........... ...........
G9117.............. Onc dx ovarian unknown NOS .................. M................. ........... ........... ........... ........... ...........
G9123.............. Onc dx CML chronic phase.. .................. M................. ........... ........... ........... ........... ...........
G9124.............. Onc dx CML acceler phase.. .................. M................. ........... ........... ........... ........... ...........
G9125.............. Onc dx CML blast phase.... .................. M................. ........... ........... ........... ........... ...........
G9126.............. Onc dx CML remission...... .................. M................. ........... ........... ........... ........... ...........
G9128.............. Onc dx multi myeloma stage .................. M................. ........... ........... ........... ........... ...........
I.
G9129.............. Onc dx mult myeloma stg2 .................. M................. ........... ........... ........... ........... ...........
hig.
G9130.............. Onc dx multi myeloma .................. M................. ........... ........... ........... ........... ...........
unknown.
G9131.............. Onc dx brst unknown NOS... .................. M................. ........... ........... ........... ........... ...........
G9132.............. Onc dx prostate mets no .................. M................. ........... ........... ........... ........... ...........
cast.
G9133.............. Onc dx prostate clinical .................. M................. ........... ........... ........... ........... ...........
met.
G9134.............. Onc NHLstg 1-2 no relap no .................. M................. ........... ........... ........... ........... ...........
G9135.............. Onc dx NHL stg 3-4 not .................. M................. ........... ........... ........... ........... ...........
relap.
G9136.............. Onc dx NHL trans to lg .................. M................. ........... ........... ........... ........... ...........
Bcell.
G9137.............. Onc dx NHL relapse/ .................. M................. ........... ........... ........... ........... ...........
refractor.
G9138.............. Onc dx NHL stg unknown.... .................. M................. ........... ........... ........... ........... ...........
G9139.............. Onc dx CML dx status .................. M................. ........... ........... ........... ........... ...........
unknown.
G9140.............. Frontier extended stay NI................ M................. ........... ........... ........... ........... ...........
demo.
J0120.............. Tetracyclin injection..... .................. N................. ........... ........... ........... ........... ...........
J0128.............. Abarelix injection........ .................. K................. 9216 ........... $67.97 ........... $13.59
J0129.............. Abatacept injection....... .................. G................. 9230 ........... $18.69 ........... $3.74
J0130.............. Abciximab injection....... .................. K................. 1605 ........... $420.17 ........... $84.03
J0132.............. Acetylcysteine injection.. CH................ N................. ........... ........... ........... ........... ...........
J0133.............. Acyclovir injection....... .................. N................. ........... ........... ........... ........... ...........
J0135.............. Adalimumab injection...... .................. K................. 1083 ........... $329.58 ........... $65.92
J0150.............. Injection adenosine 6 MG.. .................. K................. 0379 ........... $25.10 ........... $5.02
J0152.............. Adenosine injection....... .................. K................. 0917 ........... $67.89 ........... $13.58
J0170.............. Adrenalin epinephrin .................. N................. ........... ........... ........... ........... ...........
inject.
J0180.............. Agalsidase beta injection. .................. K................. 9208 ........... $126.00 ........... $25.20
J0190.............. Inj biperiden lactate/5 mg CH................ K................. 0998 ........... $88.15 ........... $17.63
J0200.............. Alatrofloxacin mesylate... .................. N................. ........... ........... ........... ........... ...........
J0205.............. Alglucerase injection..... .................. K................. 0900 ........... $38.85 ........... $7.77
J0207.............. Amifostine................ .................. K................. 7000 ........... $490.93 ........... $98.19
J0210.............. Methyldopate hcl injection .................. K................. 2210 ........... $13.04 ........... $2.61
J0215.............. Alefacept................. .................. K................. 1633 ........... $26.47 ........... $5.29
J0220.............. Aglucosidase alfa NI................ K................. 9234 ........... $126.00 ........... $25.20
injection.
J0256.............. Alpha 1 proteinase .................. K................. 0901 ........... $3.28 ........... $0.66
inhibitor.
J0270.............. Alprostadil for injection. .................. B................. ........... ........... ........... ........... ...........
J0275.............. Alprostadil urethral .................. B................. ........... ........... ........... ........... ...........
suppos.
J0278.............. Amikacin sulfate injection .................. N................. ........... ........... ........... ........... ...........
J0280.............. Aminophyllin 250 MG inj... .................. N................. ........... ........... ........... ........... ...........
J0282.............. Amiodarone HCl............ .................. N................. ........... ........... ........... ........... ...........
J0285.............. Amphotericin B............ .................. N................. ........... ........... ........... ........... ...........
J0287.............. Amphotericin b lipid .................. K................. 9024 ........... $10.40 ........... $2.08
complex.
J0288.............. Ampho b cholesteryl .................. K................. 0735 ........... $11.89 ........... $2.38
sulfate.
J0289.............. Amphotericin b liposome .................. K................. 0736 ........... $16.21 ........... $3.24
inj.
J0290.............. Ampicillin 500 MG inj..... .................. N................. ........... ........... ........... ........... ...........
J0295.............. Ampicillin sodium per 1.5 .................. N................. ........... ........... ........... ........... ...........
gm.
J0300.............. Amobarbital 125 MG inj.... .................. N................. ........... ........... ........... ........... ...........
J0330.............. Succinycholine chloride .................. N................. ........... ........... ........... ........... ...........
inj.
J0348.............. Anadulafungin injection... .................. G................. 0760 ........... $1.91 ........... $0.38
J0350.............. Injection anistreplase 30 .................. K................. 1606 ........... $2,693.80 ........... $538.76
u.
J0360.............. Hydralazine hcl injection. .................. N................. ........... ........... ........... ........... ...........
J0364.............. Apomorphine hydrochloride. CH................ N................. ........... ........... ........... ........... ...........
J0365.............. Aprotonin, 10,000 kiu..... .................. K................. 1682 ........... $2.66 ........... $0.53
J0380.............. Inj metaraminol bitartrate CH................ N................. ........... ........... ........... ........... ...........
J0390.............. Chloroquine injection..... .................. N................. ........... ........... ........... ........... ...........
J0395.............. Arbutamine HCl injection.. CH................ N................. ........... ........... ........... ........... ...........
[[Page 67140]]
J0400.............. Aripiprazole injection.... NI................ K................. 1165 ........... $0.28 ........... $0.06
J0456.............. Azithromycin.............. .................. N................. ........... ........... ........... ........... ...........
J0460.............. Atropine sulfate injection .................. N................. ........... ........... ........... ........... ...........
J0470.............. Dimecaprol injection...... .................. N................. ........... ........... ........... ........... ...........
J0475.............. Baclofen 10 MG injection.. .................. K................. 9032 ........... $193.29 ........... $38.66
J0476.............. Baclofen intrathecal trial .................. K................. 1631 ........... $69.73 ........... $13.95
J0480.............. Basiliximab............... .................. K................. 1683 ........... $1,541.03 ........... $308.21
J0500.............. Dicyclomine injection..... .................. N................. ........... ........... ........... ........... ...........
J0515.............. Inj benztropine mesylate.. .................. N................. ........... ........... ........... ........... ...........
J0520.............. Bethanechol chloride .................. N................. ........... ........... ........... ........... ...........
inject.
J0530.............. Penicillin g benzathine .................. N................. ........... ........... ........... ........... ...........
inj.
J0540.............. Penicillin g benzathine .................. N................. ........... ........... ........... ........... ...........
inj.
J0550.............. Penicillin g benzathine .................. N................. ........... ........... ........... ........... ...........
inj.
J0560.............. Penicillin g benzathine .................. N................. ........... ........... ........... ........... ...........
inj.
J0570.............. Penicillin g benzathine .................. N................. ........... ........... ........... ........... ...........
inj.
J0580.............. Penicillin g benzathine .................. N................. ........... ........... ........... ........... ...........
inj.
J0583.............. Bivalirudin............... .................. K................. 3041 ........... $1.84 ........... $0.37
J0585.............. Botulinum toxin a per unit .................. K................. 0902 ........... $5.21 ........... $1.04
J0587.............. Botulinum toxin type B.... .................. K................. 9018 ........... $8.63 ........... $1.73
J0592.............. Buprenorphine .................. N................. ........... ........... ........... ........... ...........
hydrochloride.
J0594.............. Busulfan injection........ .................. K................. 1178 ........... $9.17 ........... $1.83
J0595.............. Butorphanol tartrate 1 mg. .................. N................. ........... ........... ........... ........... ...........
J0600.............. Edetate calcium disodium CH................ K................. 0999 ........... $49.64 ........... $9.93
inj.
J0610.............. Calcium gluconate .................. N................. ........... ........... ........... ........... ...........
injection.
J0620.............. Calcium glycer & lact/10 .................. N................. ........... ........... ........... ........... ...........
ML.
J0630.............. Calcitonin salmon .................. N................. ........... ........... ........... ........... ...........
injection.
J0636.............. Inj calcitriol per 0.1 mcg .................. N................. ........... ........... ........... ........... ...........
J0637.............. Caspofungin acetate....... .................. K................. 9019 ........... $24.05 ........... $4.81
J0640.............. Leucovorin calcium .................. N................. ........... ........... ........... ........... ...........
injection.
J0670.............. Inj mepivacaine HCL/10 ml. .................. N................. ........... ........... ........... ........... ...........
J0690.............. Cefazolin sodium injection .................. N................. ........... ........... ........... ........... ...........
J0692.............. Cefepime HCl for injection .................. N................. ........... ........... ........... ........... ...........
J0694.............. Cefoxitin sodium injection .................. N................. ........... ........... ........... ........... ...........
J0696.............. Ceftriaxone sodium .................. N................. ........... ........... ........... ........... ...........
injection.
J0697.............. Sterile cefuroxime .................. N................. ........... ........... ........... ........... ...........
injection.
J0698.............. Cefotaxime sodium .................. N................. ........... ........... ........... ........... ...........
injection.
J0702.............. Betamethasone acet&sod .................. N................. ........... ........... ........... ........... ...........
phosp.
J0704.............. Betamethasone sod phosp/4 .................. N................. ........... ........... ........... ........... ...........
MG.
J0706.............. Caffeine citrate injection CH................ N................. ........... ........... ........... ........... ...........
J0710.............. Cephapirin sodium .................. N................. ........... ........... ........... ........... ...........
injection.
J0713.............. Inj ceftazidime per 500 mg .................. N................. ........... ........... ........... ........... ...........
J0715.............. Ceftizoxime sodium / 500 .................. N................. ........... ........... ........... ........... ...........
MG.
J0720.............. Chloramphenicol sodium .................. N................. ........... ........... ........... ........... ...........
injec.
J0725.............. Chorionic gonadotropin/ .................. N................. ........... ........... ........... ........... ...........
1000u.
J0735.............. Clonidine hydrochloride... .................. K................. 0935 ........... $62.78 ........... $12.56
J0740.............. Cidofovir injection....... .................. K................. 9033 ........... $754.39 ........... $150.88
J0743.............. Cilastatin sodium .................. N................. ........... ........... ........... ........... ...........
injection.
J0744.............. Ciprofloxacin iv.......... .................. N................. ........... ........... ........... ........... ...........
J0745.............. Inj codeine phosphate /30 .................. N................. ........... ........... ........... ........... ...........
MG.
J0760.............. Colchicine injection...... .................. N................. ........... ........... ........... ........... ...........
J0770.............. Colistimethate sodium inj. .................. N................. ........... ........... ........... ........... ...........
J0780.............. Prochlorperazine injection .................. N................. ........... ........... ........... ........... ...........
J0795.............. Corticorelin ovine .................. K................. 1684 ........... $4.43 ........... $0.89
triflutal.
J0800.............. Corticotropin injection... .................. K................. 1280 ........... $169.77 ........... $33.95
J0835.............. Inj cosyntropin per 0.25 .................. K................. 0835 ........... $64.01 ........... $12.80
MG.
J0850.............. Cytomegalovirus imm IV / .................. K................. 0903 ........... $870.53 ........... $174.11
vial.
J0878.............. Daptomycin injection...... .................. K................. 9124 ........... $0.35 ........... $0.07
J0881.............. Darbepoetin alfa, non-esrd .................. K................. 1685 ........... $2.88 ........... $0.58
J0882.............. Darbepoetin alfa, esrd use .................. A................. ........... ........... ........... ........... ...........
J0885.............. Epoetin alfa, non-esrd.... .................. K................. 1686 ........... $8.97 ........... $1.79
J0886.............. Epoetin alfa 1000 units .................. A................. ........... ........... ........... ........... ...........
ESRD.
J0894.............. Decitabine injection...... .................. G................. 9231 ........... $26.48 ........... $5.30
J0895.............. Deferoxamine mesylate inj. CH................ N................. ........... ........... ........... ........... ...........
J0900.............. Testosterone enanthate inj .................. N................. ........... ........... ........... ........... ...........
J0945.............. Brompheniramine maleate .................. N................. ........... ........... ........... ........... ...........
inj.
J0970.............. Estradiol valerate .................. N................. ........... ........... ........... ........... ...........
injection.
J1000.............. Depo-estradiol cypionate .................. N................. ........... ........... ........... ........... ...........
inj.
J1020.............. Methylprednisolone 20 MG .................. N................. ........... ........... ........... ........... ...........
inj.
J1030.............. Methylprednisolone 40 MG .................. N................. ........... ........... ........... ........... ...........
inj.
J1040.............. Methylprednisolone 80 MG .................. N................. ........... ........... ........... ........... ...........
inj.
J1051.............. Medroxyprogesterone inj... .................. N................. ........... ........... ........... ........... ...........
J1055.............. Medrxyprogester acetate .................. E................. ........... ........... ........... ........... ...........
inj.
J1056.............. MA/EC .................. E................. ........... ........... ........... ........... ...........
contraceptiveinjection.
J1060.............. Testosterone cypionate 1 .................. N................. ........... ........... ........... ........... ...........
ML.
J1070.............. Testosterone cypionat 100 .................. N................. ........... ........... ........... ........... ...........
MG.
J1080.............. Testosterone cypionat 200 .................. N................. ........... ........... ........... ........... ...........
MG.
J1094.............. Inj dexamethasone acetate. .................. N................. ........... ........... ........... ........... ...........
J1100.............. Dexamethasone sodium phos. .................. N................. ........... ........... ........... ........... ...........
J1110.............. Inj dihydroergotamine .................. N................. ........... ........... ........... ........... ...........
mesylt.
J1120.............. Acetazolamid sodium .................. N................. ........... ........... ........... ........... ...........
injectio.
[[Page 67141]]
J1160.............. Digoxin injection......... .................. N................. ........... ........... ........... ........... ...........
J1162.............. Digoxin immune fab (ovine) .................. K................. 1687 ........... $478.88 ........... $95.78
J1165.............. Phenytoin sodium injection .................. N................. ........... ........... ........... ........... ...........
J1170.............. Hydromorphone injection... .................. N................. ........... ........... ........... ........... ...........
J1180.............. Dyphylline injection...... .................. N................. ........... ........... ........... ........... ...........
J1190.............. Dexrazoxane HCl injection. .................. K................. 0726 ........... $162.11 ........... $32.42
J1200.............. Diphenhydramine hcl .................. N................. ........... ........... ........... ........... ...........
injectio.
J1205.............. Chlorothiazide sodium inj. .................. K................. 0747 ........... $141.07 ........... $28.21
J1212.............. Dimethyl sulfoxide 50% 50 .................. N................. ........... ........... ........... ........... ...........
ML.
J1230.............. Methadone injection....... .................. N................. ........... ........... ........... ........... ...........
J1240.............. Dimenhydrinate injection.. .................. N................. ........... ........... ........... ........... ...........
J1245.............. Dipyridamole injection.... .................. N................. ........... ........... ........... ........... ...........
J1250.............. Inj dobutamine HCL/250 mg. .................. N................. ........... ........... ........... ........... ...........
J1260.............. Dolasetron mesylate....... .................. K................. 0750 ........... $4.66 ........... $0.93
J1265.............. Dopamine injection........ .................. N................. ........... ........... ........... ........... ...........
J1270.............. Injection, doxercalciferol .................. N................. ........... ........... ........... ........... ...........
J1300.............. Eculizumab injection...... NI................ G................. 9236 ........... $176.38 ........... $35.28
J1320.............. Amitriptyline injection... .................. N................. ........... ........... ........... ........... ...........
J1324.............. Enfuvirtide injection..... .................. K................. 0767 ........... $0.40 ........... $0.08
J1325.............. Epoprostenol injection.... .................. N................. ........... ........... ........... ........... ...........
J1327.............. Eptifibatide injection.... .................. K................. 1607 ........... $17.67 ........... $3.53
J1330.............. Ergonovine maleate CH................ N................. ........... ........... ........... ........... ...........
injection.
J1335.............. Ertapenem injection....... .................. N................. ........... ........... ........... ........... ...........
J1364.............. Erythro lactobionate /500 .................. N................. ........... ........... ........... ........... ...........
MG.
J1380.............. Estradiol valerate 10 MG .................. N................. ........... ........... ........... ........... ...........
inj.
J1390.............. Estradiol valerate 20 MG .................. N................. ........... ........... ........... ........... ...........
inj.
J1410.............. Inj estrogen conjugate 25 .................. K................. 9038 ........... $66.64 ........... $13.33
MG.
J1430.............. Ethanolamine oleate 100 mg .................. K................. 1688 ........... $79.23 ........... $15.85
J1435.............. Injection estrone per 1 MG .................. N................. ........... ........... ........... ........... ...........
J1436.............. Etidronate disodium inj... .................. K................. 1436 ........... $70.73 ........... $14.15
J1438.............. Etanercept injection...... .................. K................. 1608 ........... $167.12 ........... $33.42
J1440.............. Filgrastim 300 mcg .................. K................. 0728 ........... $193.79 ........... $38.76
injection.
J1441.............. Filgrastim 480 mcg .................. K................. 7049 ........... $298.39 ........... $59.68
injection.
J1450.............. Fluconazole............... .................. N................. ........... ........... ........... ........... ...........
J1451.............. Fomepizole, 15 mg......... .................. K................. 1689 ........... $12.80 ........... $2.56
J1452.............. Intraocular Fomivirsen na. CH................ N................. ........... ........... ........... ........... ...........
J1455.............. Foscarnet sodium injection CH................ N................. ........... ........... ........... ........... ...........
J1457.............. Gallium nitrate injection. CH................ K................. 0878 ........... $1.61 ........... $0.32
J1458.............. Galsulfase injection...... .................. K................. 9224 ........... $306.88 ........... $61.38
J1460.............. Gamma globulin 1 CC inj... .................. K................. 3043 ........... $11.91 ........... $2.38
J1470.............. Gamma globulin 2 CC inj... CH................ K................. 0898 ........... $23.82 ........... $4.76
J1480.............. Gamma globulin 3 CC inj... CH................ K................. 0899 ........... $35.72 ........... $7.14
J1490.............. Gamma globulin 4 CC inj... CH................ K................. 0904 ........... $47.64 ........... $9.53
J1500.............. Gamma globulin 5 CC inj... CH................ K................. 0919 ........... $59.54 ........... $11.91
J1510.............. Gamma globulin 6 CC inj... CH................ K................. 0920 ........... $71.50 ........... $14.30
J1520.............. Gamma globulin 7 CC inj... CH................ K................. 0921 ........... $83.30 ........... $16.66
J1530.............. Gamma globulin 8 CC inj... CH................ K................. 0922 ........... $95.27 ........... $19.05
J1540.............. Gamma globulin 9 CC inj... CH................ K................. 0923 ........... $107.25 ........... $21.45
J1550.............. Gamma globulin 10 CC inj.. CH................ K................. 0924 ........... $119.09 ........... $23.82
J1560.............. Gamma globulin > 10 CC inj CH................ K................. 0933 ........... $119.09 ........... $23.82
J1561.............. Gamunex injection......... NI................ K................. 0948 ........... $32.06 ........... $6.41
J1562.............. Vivaglobin, inj........... .................. K................. 0804 ........... $7.01 ........... $1.40
J1565.............. RSV-ivig.................. .................. K................. 0906 ........... $16.02 ........... $3.20
J1566.............. Immune globulin, powder... .................. K................. 2731 ........... $26.89 ........... $5.38
J1567.............. Immune globulin, liquid... CH................ D................. ........... ........... ........... ........... ...........
J1568.............. Octagam injection......... NI................ K................. 0943 ........... $33.19 ........... $6.64
J1569.............. Gammagard liquid injection NI................ K................. 0944 ........... $31.06 ........... $6.21
J1570.............. Ganciclovir sodium .................. N................. ........... ........... ........... ........... ...........
injection.
J1571.............. HepaGam B IM injection.... NI................ K................. 0946 ........... $63.51 ........... $12.70
J1572.............. Flebogamma injection...... NI................ K................. 0947 ........... $32.27 ........... $6.45
J1573.............. Hepagam B intravenous, inj NI................ K................. 1138 ........... $63.51 ........... $12.70
J1580.............. Garamycin gentamicin inj.. .................. N................. ........... ........... ........... ........... ...........
J1590.............. Gatifloxacin injection.... .................. N................. ........... ........... ........... ........... ...........
J1595.............. Injection glatiramer CH................ K................. 1015 ........... $52.04 ........... $10.41
acetate.
J1600.............. Gold sodium thiomaleate .................. N................. ........... ........... ........... ........... ...........
inj.
J1610.............. Glucagon hydrochloride/1 .................. K................. 9042 ........... $68.84 ........... $13.77
MG.
J1620.............. Gonadorelin hydroch/ 100 .................. K................. 7005 ........... $178.59 ........... $35.72
mcg.
J1626.............. Granisetron HCl injection. .................. K................. 0764 ........... $5.74 ........... $1.15
J1630.............. Haloperidol injection..... .................. N................. ........... ........... ........... ........... ...........
J1631.............. Haloperidol decanoate inj. .................. N................. ........... ........... ........... ........... ...........
J1640.............. Hemin, 1 mg............... .................. K................. 1690 ........... $7.08 ........... $1.42
J1642.............. Inj heparin sodium per 10 .................. N................. ........... ........... ........... ........... ...........
u.
J1644.............. Inj heparin sodium per .................. N................. ........... ........... ........... ........... ...........
1000u.
J1645.............. Dalteparin sodium......... .................. N................. ........... ........... ........... ........... ...........
J1650.............. Inj enoxaparin sodium..... .................. N................. ........... ........... ........... ........... ...........
J1652.............. Fondaparinux sodium....... CH................ K................. 0883 ........... $5.92 ........... $1.18
J1655.............. Tinzaparin sodium CH................ N................. ........... ........... ........... ........... ...........
injection.
J1670.............. Tetanus immune globulin .................. K................. 1670 ........... $103.46 ........... $20.69
inj.
J1675.............. Histrelin acetate......... .................. B................. ........... ........... ........... ........... ...........
J1700.............. Hydrocortisone acetate inj .................. N................. ........... ........... ........... ........... ...........
[[Page 67142]]
J1710.............. Hydrocortisone sodium ph .................. N................. ........... ........... ........... ........... ...........
inj.
J1720.............. Hydrocortisone sodium succ .................. N................. ........... ........... ........... ........... ...........
i.
J1730.............. Diazoxide injection....... .................. K................. 1740 ........... $113.24 ........... $22.65
J1740.............. Ibandronate sodium .................. G................. 9229 ........... $138.96 ........... $27.79
injection.
J1742.............. Ibutilide fumarate .................. K................. 9044 ........... $287.15 ........... $57.43
injection.
J1743.............. Idursulfase injection..... NI................ G................. 9232 ........... $455.03 ........... $91.01
J1745.............. Infliximab injection...... .................. K................. 7043 ........... $54.42 ........... $10.88
J1751.............. Iron dextran 165 injection .................. K................. 1691 ........... $11.82 ........... $2.36
J1752.............. Iron dextran 267 injection .................. K................. 1692 ........... $10.30 ........... $2.06
J1756.............. Iron sucrose injection.... .................. K................. 9046 ........... $0.36 ........... $0.08
J1785.............. Injection imiglucerase / .................. K................. 0916 ........... $3.89 ........... $0.78
unit.
J1790.............. Droperidol injection...... .................. N................. ........... ........... ........... ........... ...........
J1800.............. Propranolol injection..... .................. N................. ........... ........... ........... ........... ...........
J1810.............. Droperidol/fentanyl inj... .................. E................. ........... ........... ........... ........... ...........
J1815.............. Insulin injection......... .................. N................. ........... ........... ........... ........... ...........
J1817.............. Insulin for insulin pump .................. N................. ........... ........... ........... ........... ...........
use.
J1825.............. Interferon beta-1a........ .................. E................. ........... ........... ........... ........... ...........
J1830.............. Interferon beta-1b / .25 .................. K................. 0910 ........... $106.57 ........... $21.31
MG.
J1835.............. Itraconazole injection.... .................. K................. 9047 ........... $39.68 ........... $7.94
J1840.............. Kanamycin sulfate 500 MG .................. N................. ........... ........... ........... ........... ...........
inj.
J1850.............. Kanamycin sulfate 75 MG .................. N................. ........... ........... ........... ........... ...........
inj.
J1885.............. Ketorolac tromethamine inj .................. N................. ........... ........... ........... ........... ...........
J1890.............. Cephalothin sodium .................. N................. ........... ........... ........... ........... ...........
injection.
J1931.............. Laronidase injection...... .................. K................. 9209 ........... $23.64 ........... $4.73
J1940.............. Furosemide injection...... .................. N................. ........... ........... ........... ........... ...........
J1945.............. Lepirudin................. .................. K................. 1693 ........... $159.44 ........... $31.89
J1950.............. Leuprolide acetate /3.75 .................. K................. 0800 ........... $452.58 ........... $90.52
MG.
J1955.............. Inj levocarnitine per 1 gm .................. B................. ........... ........... ........... ........... ...........
J1956.............. Levofloxacin injection.... .................. N................. ........... ........... ........... ........... ...........
J1960.............. Levorphanol tartrate inj.. .................. N................. ........... ........... ........... ........... ...........
J1980.............. Hyoscyamine sulfate inj... .................. N................. ........... ........... ........... ........... ...........
J1990.............. Chlordiazepoxide injection .................. N................. ........... ........... ........... ........... ...........
J2001.............. Lidocaine injection....... .................. N................. ........... ........... ........... ........... ...........
J2010.............. Lincomycin injection...... .................. N................. ........... ........... ........... ........... ...........
J2020.............. Linezolid injection....... .................. K................. 9001 ........... $25.17 ........... $5.03
J2060.............. Lorazepam injection....... .................. N................. ........... ........... ........... ........... ...........
J2150.............. Mannitol injection........ .................. N................. ........... ........... ........... ........... ...........
J2170.............. Mecasermin injection...... .................. K................. 0805 ........... $15.62 ........... $3.12
J2175.............. Meperidine hydrochl /100 .................. N................. ........... ........... ........... ........... ...........
MG.
J2180.............. Meperidine/promethazine .................. N................. ........... ........... ........... ........... ...........
inj.
J2185.............. Meropenem................. CH................ N................. ........... ........... ........... ........... ...........
J2210.............. Methylergonovin maleate .................. N................. ........... ........... ........... ........... ...........
inj.
J2248.............. Micafungin sodium .................. G................. 9227 ........... $1.44 ........... $0.29
injection.
J2250.............. Inj midazolam .................. N................. ........... ........... ........... ........... ...........
hydrochloride.
J2260.............. Inj milrinone lactate / 5 .................. N................. ........... ........... ........... ........... ...........
MG.
J2270.............. Morphine sulfate injection .................. N................. ........... ........... ........... ........... ...........
J2271.............. Morphine so4 injection .................. N................. ........... ........... ........... ........... ...........
100mg.
J2275.............. Morphine sulfate injection .................. N................. ........... ........... ........... ........... ...........
J2278.............. Ziconotide injection...... CH................ K................. 1694 ........... $6.46 ........... $1.29
J2280.............. Inj, moxifloxacin 100 mg.. .................. N................. ........... ........... ........... ........... ...........
J2300.............. Inj nalbuphine .................. N................. ........... ........... ........... ........... ...........
hydrochloride.
J2310.............. Inj naloxone hydrochloride .................. N................. ........... ........... ........... ........... ...........
J2315.............. Naltrexone, depot form.... .................. K................. 0759 ........... $1.87 ........... $0.37
J2320.............. Nandrolone decanoate 50 MG .................. N................. ........... ........... ........... ........... ...........
J2321.............. Nandrolone decanoate 100 .................. N................. ........... ........... ........... ........... ...........
MG.
J2322.............. Nandrolone decanoate 200 .................. N................. ........... ........... ........... ........... ...........
MG.
J2323.............. Natalizumab injection..... NI................ G................. 9126 ........... $7.51 ........... $1.50
J2325.............. Nesiritide injection...... .................. K................. 1695 ........... $32.95 ........... $6.59
J2353.............. Octreotide injection, .................. K................. 1207 ........... $99.04 ........... $19.81
depot.
J2354.............. Octreotide inj, non-depot. .................. N................. ........... ........... ........... ........... ...........
J2355.............. Oprelvekin injection...... .................. K................. 7011 ........... $247.02 ........... $49.40
J2357.............. Omalizumab injection...... .................. K................. 9300 ........... $17.12 ........... $3.42
J2360.............. Orphenadrine injection.... .................. N................. ........... ........... ........... ........... ...........
J2370.............. Phenylephrine hcl .................. N................. ........... ........... ........... ........... ...........
injection.
J2400.............. Chloroprocaine hcl .................. N................. ........... ........... ........... ........... ...........
injection.
J2405.............. Ondansetron hcl injection. .................. K................. 0768 ........... $0.26 ........... $0.06
J2410.............. Oxymorphone hcl injection. .................. N................. ........... ........... ........... ........... ...........
J2425.............. Palifermin injection...... .................. K................. 1696 ........... $11.24 ........... $2.25
J2430.............. Pamidronate disodium /30 .................. K................. 0730 ........... $28.31 ........... $5.66
MG.
J2440.............. Papaverin hcl injection... .................. N................. ........... ........... ........... ........... ...........
J2460.............. Oxytetracycline injection. .................. N................. ........... ........... ........... ........... ...........
J2469.............. Palonosetron HCl.......... .................. K................. 9210 ........... $16.45 ........... $3.29
J2501.............. Paricalcitol.............. .................. N................. ........... ........... ........... ........... ...........
J2503.............. Pegaptanib sodium CH................ K................. 1697 ........... $1,035.69 ........... $207.14
injection.
J2504.............. Pegademase bovine, 25 iu.. .................. K................. 1739 ........... $197.51 ........... $39.50
J2505.............. Injection, pegfilgrastim .................. K................. 9119 ........... $2,145.12 ........... $429.02
6mg.
J2510.............. Penicillin g procaine inj. .................. N................. ........... ........... ........... ........... ...........
J2513.............. Pentastarch 10% solution.. CH................ K................. 0880 ........... $21.98 ........... $4.40
J2515.............. Pentobarbital sodium inj.. .................. N................. ........... ........... ........... ........... ...........
J2540.............. Penicillin g potassium inj .................. N................. ........... ........... ........... ........... ...........
[[Page 67143]]
J2543.............. Piperacillin/tazobactam... .................. N................. ........... ........... ........... ........... ...........
J2545.............. Pentamidine non-comp unit. .................. B................. ........... ........... ........... ........... ...........
J2550.............. Promethazine hcl injection .................. N................. ........... ........... ........... ........... ...........
J2560.............. Phenobarbital sodium inj.. .................. N................. ........... ........... ........... ........... ...........
J2590.............. Oxytocin injection........ .................. N................. ........... ........... ........... ........... ...........
J2597.............. Inj desmopressin acetate.. .................. N................. ........... ........... ........... ........... ...........
J2650.............. Prednisolone acetate inj.. .................. N................. ........... ........... ........... ........... ...........
J2670.............. Totazoline hcl injection.. .................. N................. ........... ........... ........... ........... ...........
J2675.............. Inj progesterone per 50 MG .................. N................. ........... ........... ........... ........... ...........
J2680.............. Fluphenazine decanoate 25 .................. N................. ........... ........... ........... ........... ...........
MG.
J2690.............. Procainamide hcl injection .................. N................. ........... ........... ........... ........... ...........
J2700.............. Oxacillin sodium injeciton .................. N................. ........... ........... ........... ........... ...........
J2710.............. Neostigmine methylslfte .................. N................. ........... ........... ........... ........... ...........
inj.
J2720.............. Inj protamine sulfate/10 .................. N................. ........... ........... ........... ........... ...........
MG.
J2724.............. Protein C concentrate..... NI................ K................. 1139 ........... $12.08 ........... $2.42
J2725.............. Inj protirelin per 250 mcg .................. N................. ........... ........... ........... ........... ...........
J2730.............. Pralidoxime chloride inj.. CH................ K................. 1023 ........... $35.20 ........... $7.04
J2760.............. Phentolaine mesylate inj.. .................. N................. ........... ........... ........... ........... ...........
J2765.............. Metoclopramide hcl .................. N................. ........... ........... ........... ........... ...........
injection.
J2770.............. Quinupristin/dalfopristin. .................. K................. 2770 ........... $126.44 ........... $25.29
J2778.............. Ranibizumab injection..... NI................ G................. 9233 ........... $2,030.23 ........... $406.05
J2780.............. Ranitidine hydrochloride .................. N................. ........... ........... ........... ........... ...........
inj.
J2783.............. Rasburicase............... .................. K................. 0738 ........... $144.43 ........... $28.89
J2788.............. Rho d immune globulin 50 .................. K................. 9023 ........... $26.41 ........... $5.28
mcg.
J2790.............. Rho d immune globulin inj. .................. K................. 0884 ........... $80.79 ........... $16.16
J2791.............. Rhophylac injection....... NI................ K................. 0945 ........... $5.29 ........... $1.06
J2792.............. Rho(D) immune globulin h, .................. K................. 1609 ........... $15.62 ........... $3.12
sd.
J2794.............. Risperidone, long acting.. .................. K................. 9125 ........... $4.86 ........... $0.97
J2795.............. Ropivacaine HCl injection. .................. N................. ........... ........... ........... ........... ...........
J2800.............. Methocarbamol injection... .................. N................. ........... ........... ........... ........... ...........
J2805.............. Sincalide injection....... .................. N................. ........... ........... ........... ........... ...........
J2810.............. Inj theophylline per 40 MG .................. N................. ........... ........... ........... ........... ...........
J2820.............. Sargramostim injection.... .................. K................. 0731 ........... $24.86 ........... $4.97
J2850.............. Inj secretin synthetic .................. K................. 1700 ........... $20.12 ........... $4.02
human.
J2910.............. Aurothioglucose injeciton. .................. N................. ........... ........... ........... ........... ...........
J2916.............. Na ferric gluconate .................. N................. ........... ........... ........... ........... ...........
complex.
J2920.............. Methylprednisolone .................. N................. ........... ........... ........... ........... ...........
injection.
J2930.............. Methylprednisolone .................. N................. ........... ........... ........... ........... ...........
injection.
J2940.............. Somatrem injection........ .................. K................. 2940 ........... $168.90 ........... $33.78
J2941.............. Somatropin injection...... .................. K................. 7034 ........... $48.52 ........... $9.70
J2950.............. Promazine hcl injection... .................. N................. ........... ........... ........... ........... ...........
J2993.............. Reteplase injection....... .................. K................. 9005 ........... $841.28 ........... $168.26
J2995.............. Inj streptokinase /250000 .................. K................. 0911 ........... $129.75 ........... $25.95
IU.
J2997.............. Alteplase recombinant..... .................. K................. 7048 ........... $33.39 ........... $6.68
J3000.............. Streptomycin injection.... .................. N................. ........... ........... ........... ........... ...........
J3010.............. Fentanyl citrate injeciton .................. N................. ........... ........... ........... ........... ...........
J3030.............. Sumatriptan succinate / 6 .................. K................. 3030 ........... $61.27 ........... $12.25
MG.
J3070.............. Pentazocine injection..... .................. N................. ........... ........... ........... ........... ...........
J3100.............. Tenecteplase injection.... .................. K................. 9002 ........... $2,034.65 ........... $406.93
J3105.............. Terbutaline sulfate inj... .................. N................. ........... ........... ........... ........... ...........
J3110.............. Teriparatide injection.... .................. B................. ........... ........... ........... ........... ...........
J3120.............. Testosterone enanthate inj .................. N................. ........... ........... ........... ........... ...........
J3130.............. Testosterone enanthate inj .................. N................. ........... ........... ........... ........... ...........
J3140.............. Testosterone suspension .................. N................. ........... ........... ........... ........... ...........
inj.
J3150.............. Testosteron propionate inj .................. N................. ........... ........... ........... ........... ...........
J3230.............. Chlorpromazine hcl .................. N................. ........... ........... ........... ........... ...........
injection.
J3240.............. Thyrotropin injection..... .................. K................. 9108 ........... $834.18 ........... $166.84
J3243.............. Tigecycline injection..... .................. G................. 9228 ........... $0.96 ........... $0.19
J3246.............. Tirofiban HCl............. .................. K................. 7041 ........... $7.56 ........... $1.51
J3250.............. Trimethobenzamide hcl inj. .................. N................. ........... ........... ........... ........... ...........
J3260.............. Tobramycin sulfate .................. N................. ........... ........... ........... ........... ...........
injection.
J3265.............. Injection torsemide 10 mg/ .................. N................. ........... ........... ........... ........... ...........
ml.
J3280.............. Thiethylperazine maleate .................. N................. ........... ........... ........... ........... ...........
inj.
J3285.............. Treprostinil injection.... .................. K................. 1701 ........... $55.36 ........... $11.07
J3301.............. Triamcinolone acetonide .................. N................. ........... ........... ........... ........... ...........
inj.
J3302.............. Triamcinolone diacetate .................. N................. ........... ........... ........... ........... ...........
inj.
J3303.............. Triamcinolone hexacetonl .................. N................. ........... ........... ........... ........... ...........
inj.
J3305.............. Inj trimetrexate .................. K................. 7045 ........... $148.30 ........... $29.66
glucoronate.
J3310.............. Perphenazine injeciton.... .................. N................. ........... ........... ........... ........... ...........
J3315.............. Triptorelin pamoate....... .................. K................. 9122 ........... $159.38 ........... $31.88
J3320.............. Spectinomycn di-hcl inj... CH................ N................. ........... ........... ........... ........... ...........
J3350.............. Urea injection............ .................. K................. 9051 ........... $74.16 ........... $14.83
J3355.............. Urofollitropin, 75 iu..... .................. K................. 1741 ........... $50.22 ........... $10.04
J3360.............. Diazepam injection........ .................. N................. ........... ........... ........... ........... ...........
J3364.............. Urokinase 5000 IU .................. N................. ........... ........... ........... ........... ...........
injection.
J3365.............. Urokinase 250,000 IU inj.. .................. K................. 7036 ........... $453.41 ........... $90.68
J3370.............. Vancomycin hcl injection.. .................. N................. ........... ........... ........... ........... ...........
J3396.............. Verteporfin injection..... .................. K................. 1203 ........... $8.99 ........... $1.80
J3400.............. Triflupromazine hcl inj... .................. N................. ........... ........... ........... ........... ...........
J3410.............. Hydroxyzine hcl injection. .................. N................. ........... ........... ........... ........... ...........
[[Page 67144]]
J3411.............. Thiamine hcl 100 mg....... .................. N................. ........... ........... ........... ........... ...........
J3415.............. Pyridoxine hcl 100 mg..... .................. N................. ........... ........... ........... ........... ...........
J3420.............. Vitamin b12 injection..... .................. N................. ........... ........... ........... ........... ...........
J3430.............. Vitamin k phytonadione inj .................. N................. ........... ........... ........... ........... ...........
J3465.............. Injection, voriconazole... .................. K................. 1052 ........... $4.93 ........... $0.99
J3470.............. Hyaluronidase injection... .................. N................. ........... ........... ........... ........... ...........
J3471.............. Ovine, up to 999 USP units .................. N................. ........... ........... ........... ........... ...........
J3472.............. Ovine, 1000 USP units..... .................. K................. 1703 ........... $133.77 ........... $26.75
J3473.............. Hyaluronidase recombinant. .................. G................. 0806 ........... $0.40 ........... $0.08
J3475.............. Inj magnesium sulfate..... .................. N................. ........... ........... ........... ........... ...........
J3480.............. Inj potassium chloride.... .................. N................. ........... ........... ........... ........... ...........
J3485.............. Zidovudine................ .................. N................. ........... ........... ........... ........... ...........
J3486.............. Ziprasidone mesylate...... .................. N................. ........... ........... ........... ........... ...........
J3487.............. Zoledronic acid........... .................. K................. 9115 ........... $205.76 ........... $41.15
J3488.............. Reclast injection......... NI................ G................. 0951 ........... $220.81 ........... $44.16
J3490.............. Drugs unclassified .................. N................. ........... ........... ........... ........... ...........
injection.
J3520.............. Edetate disodium per 150 .................. E................. ........... ........... ........... ........... ...........
mg.
J3530.............. Nasal vaccine inhalation.. .................. N................. ........... ........... ........... ........... ...........
J3535.............. Metered dose inhaler drug. .................. E................. ........... ........... ........... ........... ...........
J3570.............. Laetrile amygdalin vit B17 .................. E................. ........... ........... ........... ........... ...........
J3590.............. Unclassified biologics.... .................. N................. ........... ........... ........... ........... ...........
J7030.............. Normal saline solution .................. N................. ........... ........... ........... ........... ...........
infus.
J7040.............. Normal saline solution .................. N................. ........... ........... ........... ........... ...........
infus.
J7042.............. 5% dextrose/normal saline. .................. N................. ........... ........... ........... ........... ...........
J7050.............. Normal saline solution .................. N................. ........... ........... ........... ........... ...........
infus.
J7060.............. 5% dextrose/water......... .................. N................. ........... ........... ........... ........... ...........
J7070.............. D5w infusion.............. .................. N................. ........... ........... ........... ........... ...........
J7100.............. Dextran 40 infusion....... .................. N................. ........... ........... ........... ........... ...........
J7110.............. Dextran 75 infusion....... .................. N................. ........... ........... ........... ........... ...........
J7120.............. Ringers lactate infusion.. .................. N................. ........... ........... ........... ........... ...........
J7130.............. Hypertonic saline solution .................. N................. ........... ........... ........... ........... ...........
J7187.............. Humate-P, inj............. .................. K................. 1704 ........... $0.88 ........... $0.18
J7189.............. Factor viia............... .................. K................. 1705 ........... $1.15 ........... $0.23
J7190.............. Factor viii............... .................. K................. 0925 ........... $0.75 ........... $0.15
J7191.............. Factor VIII (porcine)..... CH................ N................. ........... ........... ........... ........... ...........
J7192.............. Factor viii recombinant... .................. K................. 0927 ........... $1.07 ........... $0.21
J7193.............. Factor IX non-recombinant. .................. K................. 0931 ........... $0.89 ........... $0.18
J7194.............. Factor ix complex......... .................. K................. 0928 ........... $0.80 ........... $0.16
J7195.............. Factor IX recombinant..... .................. K................. 0932 ........... $0.99 ........... $0.20
J7197.............. Antithrombin iii injection .................. K................. 0930 ........... $1.82 ........... $0.36
J7198.............. Anti-inhibitor............ .................. K................. 0929 ........... $1.42 ........... $0.28
J7199.............. Hemophilia clot factor noc .................. B................. ........... ........... ........... ........... ...........
J7300.............. Intraut copper .................. E................. ........... ........... ........... ........... ...........
contraceptive.
J7302.............. Levonorgestrel iu .................. E................. ........... ........... ........... ........... ...........
contracept.
J7303.............. Contraceptive vaginal ring .................. E................. ........... ........... ........... ........... ...........
J7304.............. Contraceptive hormone .................. E................. ........... ........... ........... ........... ...........
patch.
J7306.............. Levonorgestrel implant sys .................. E................. ........... ........... ........... ........... ...........
J7307.............. Etonogestrel implant NI................ E................. ........... ........... ........... ........... ...........
system.
J7308.............. Aminolevulinic acid hcl .................. K................. 7308 ........... $109.92 ........... $21.98
top.
J7310.............. Ganciclovir long act .................. K................. 0913 ........... $4,707.90 ........... $941.58
implant.
J7311.............. Fluocinolone acetonide CH................ K................. 9225 ........... $19,162.50 ........... $3,832.50
implt.
J7321.............. Hyalgan/supartz inj per NI................ K................. 0873 ........... $101.81 ........... $20.36
dose.
J7322.............. Synvisc inj per dose...... NI................ K................. 0874 ........... $178.11 ........... $35.62
J7323.............. Euflexxa inj per dose..... NI................ K................. 0875 ........... $110.95 ........... $22.19
J7324.............. Orthovisc inj per dose.... NI................ K................. 0877 ........... $174.50 ........... $34.90
J7330.............. Cultured chondrocytes .................. B................. ........... ........... ........... ........... ...........
implnt.
J7340.............. Metabolic active D/E .................. K................. 1632 ........... $28.45 ........... $5.69
tissue.
J7341.............. Non-human, metabolic CH................ N................. ........... ........... ........... ........... ...........
tissue.
J7342.............. Metabolically active .................. K................. 9054 ........... $36.40 ........... $7.28
tissue.
J7343.............. Nonmetabolic act d/e .................. K................. 1629 ........... $20.22 ........... $4.04
tissue.
J7344.............. Nonmetabolic active tissue .................. K................. 9156 ........... $94.53 ........... $18.91
J7345.............. Non-human, non-metab CH................ D................. ........... ........... ........... ........... ...........
tissue.
J7346.............. Injectable human tissue... .................. K................. 9222 ........... $774.46 ........... $154.89
J7347.............. Integra matrix tissue..... NI................ K................. 1140 ........... $33.14 ........... $6.63
J7348.............. Tissuemend tissue......... NI................ G................. 9351 ........... $67.96 ........... $13.59
J7349.............. Primatrix tissue.......... NI................ G................. 1141 ........... $67.96 ........... $13.59
J7500.............. Azathioprine oral 50mg.... .................. N................. ........... ........... ........... ........... ...........
J7501.............. Azathioprine parenteral... .................. K................. 0887 ........... $47.88 ........... $9.58
J7502.............. Cyclosporine oral 100 mg.. .................. K................. 0888 ........... $3.52 ........... $0.70
J7504.............. Lymphocyte immune globulin .................. K................. 0890 ........... $336.10 ........... $67.22
J7505.............. Monoclonal antibodies..... .................. K................. 7038 ........... $977.75 ........... $195.55
J7506.............. Prednisone oral........... .................. N................. ........... ........... ........... ........... ...........
J7507.............. Tacrolimus oral per 1 MG.. .................. K................. 0891 ........... $3.69 ........... $0.74
J7509.............. Methylprednisolone oral... .................. N................. ........... ........... ........... ........... ...........
J7510.............. Prednisolone oral per 5 mg .................. N................. ........... ........... ........... ........... ...........
J7511.............. Antithymocyte globuln .................. K................. 9104 ........... $337.82 ........... $67.56
rabbit.
J7513.............. Daclizumab, parenteral.... .................. K................. 1612 ........... $322.28 ........... $64.46
J7515.............. Cyclosporine oral 25 mg... .................. N................. ........... ........... ........... ........... ...........
J7516.............. Cyclosporin parenteral .................. N................. ........... ........... ........... ........... ...........
250mg.
J7517.............. Mycophenolate mofetil oral .................. K................. 9015 ........... $2.66 ........... $0.53
[[Page 67145]]
J7518.............. Mycophenolic acid......... .................. K................. 9219 ........... $2.41 ........... $0.48
J7520.............. Sirolimus, oral........... .................. K................. 9020 ........... $7.50 ........... $1.50
J7525.............. Tacrolimus injection...... .................. K................. 9006 ........... $138.64 ........... $27.73
J7599.............. Immunosuppressive drug noc .................. N................. ........... ........... ........... ........... ...........
J7602.............. Albuterol inh non-comp con NI................ M................. ........... ........... ........... ........... ...........
J7603.............. Albuterol inh non-comp u d NI................ M................. ........... ........... ........... ........... ...........
J7604.............. Acetylcysteine comp unit.. NI................ M................. ........... ........... ........... ........... ...........
J7605.............. Arformoterol non-comp unit NI................ M................. ........... ........... ........... ........... ...........
J7607.............. Levalbuterol comp con..... CH................ M................. ........... ........... ........... ........... ...........
J7608.............. Acetylcysteine non-comp CH................ M................. ........... ........... ........... ........... ...........
unit.
J7609.............. Albuterol comp unit....... CH................ M................. ........... ........... ........... ........... ...........
J7610.............. Albuterol comp con........ CH................ M................. ........... ........... ........... ........... ...........
J7611.............. Albuterol non-comp con.... CH................ D................. ........... ........... ........... ........... ...........
J7612.............. Levalbuterol non-comp con. CH................ D................. ........... ........... ........... ........... ...........
J7613.............. Albuterol non-comp unit... CH................ D................. ........... ........... ........... ........... ...........
J7614.............. Levalbuterol non-comp unit CH................ D................. ........... ........... ........... ........... ...........
J7615.............. Levalbuterol comp unit.... CH................ M................. ........... ........... ........... ........... ...........
J7620.............. Albuterol ipratrop non- CH................ M................. ........... ........... ........... ........... ...........
comp.
J7622.............. Beclomethasone comp unit.. CH................ M................. ........... ........... ........... ........... ...........
J7624.............. Betamethasone comp unit... CH................ M................. ........... ........... ........... ........... ...........
J7626.............. Budesonide non-comp unit.. CH................ M................. ........... ........... ........... ........... ...........
J7627.............. Budesonide comp unit...... CH................ M................. ........... ........... ........... ........... ...........
J7628.............. Bitolterol mesylate comp CH................ M................. ........... ........... ........... ........... ...........
con.
J7629.............. Bitolterol mesylate comp CH................ M................. ........... ........... ........... ........... ...........
unt.
J7631.............. Cromolyn sodium noncomp CH................ M................. ........... ........... ........... ........... ...........
unit.
J7632.............. Cromolyn sodium comp unit. NI................ M................. ........... ........... ........... ........... ...........
J7633.............. Budesonide non-comp con... CH................ M................. ........... ........... ........... ........... ...........
J7634.............. Budesonide comp con....... CH................ M................. ........... ........... ........... ........... ...........
J7635.............. Atropine comp con......... CH................ M................. ........... ........... ........... ........... ...........
J7636.............. Atropine comp unit........ CH................ M................. ........... ........... ........... ........... ...........
J7637.............. Dexamethasone comp con.... CH................ M................. ........... ........... ........... ........... ...........
J7638.............. Dexamethasone comp unit... CH................ M................. ........... ........... ........... ........... ...........
J7639.............. Dornase alpha non-comp CH................ M................. ........... ........... ........... ........... ...........
unit.
J7640.............. Formoterol comp unit...... .................. E................. ........... ........... ........... ........... ...........
J7641.............. Flunisolide comp unit..... CH................ M................. ........... ........... ........... ........... ...........
J7642.............. Glycopyrrolate comp con... CH................ M................. ........... ........... ........... ........... ...........
J7643.............. Glycopyrrolate comp unit.. CH................ M................. ........... ........... ........... ........... ...........
J7644.............. Ipratropium bromide non- CH................ M................. ........... ........... ........... ........... ...........
comp.
J7645.............. Ipratropium bromide comp.. CH................ M................. ........... ........... ........... ........... ...........
J7647.............. Isoetharine comp con...... CH................ M................. ........... ........... ........... ........... ...........
J7648.............. Isoetharine non-comp con.. CH................ M................. ........... ........... ........... ........... ...........
J7649.............. Isoetharine non-comp unit. CH................ M................. ........... ........... ........... ........... ...........
J7650.............. Isoetharine comp unit..... CH................ M................. ........... ........... ........... ........... ...........
J7657.............. Isoproterenol comp con.... CH................ M................. ........... ........... ........... ........... ...........
J7658.............. Isoproterenol non-comp con CH................ M................. ........... ........... ........... ........... ...........
J7659.............. Isoproterenol non-comp CH................ M................. ........... ........... ........... ........... ...........
unit.
J7660.............. Isoproterenol comp unit... CH................ M................. ........... ........... ........... ........... ...........
J7667.............. Metaproterenol comp con... CH................ M................. ........... ........... ........... ........... ...........
J7668.............. Metaproterenol non-comp CH................ M................. ........... ........... ........... ........... ...........
con.
J7669.............. Metaproterenol non-comp CH................ M................. ........... ........... ........... ........... ...........
unit.
J7670.............. Metaproterenol comp unit.. CH................ M................. ........... ........... ........... ........... ...........
J7674.............. Methacholine chloride, neb .................. N................. ........... ........... ........... ........... ...........
J7676.............. Pentamidine comp unit dose NI................ M................. ........... ........... ........... ........... ...........
J7680.............. Terbutaline sulf comp con. CH................ M................. ........... ........... ........... ........... ...........
J7681.............. Terbutaline sulf comp unit CH................ M................. ........... ........... ........... ........... ...........
J7682.............. Tobramycin non-comp unit.. CH................ M................. ........... ........... ........... ........... ...........
J7683.............. Triamcinolone comp con.... CH................ M................. ........... ........... ........... ........... ...........
J7684.............. Triamcinolone comp unit... CH................ M................. ........... ........... ........... ........... ...........
J7685.............. Tobramycin comp unit...... CH................ M................. ........... ........... ........... ........... ...........
J7699.............. Inhalation solution for CH................ M................. ........... ........... ........... ........... ...........
DME.
J7799.............. Non-inhalation drug for .................. N................. ........... ........... ........... ........... ...........
DME.
J8498.............. Antiemetic rectal/supp NOS .................. B................. ........... ........... ........... ........... ...........
J8499.............. Oral prescrip drug non .................. E................. ........... ........... ........... ........... ...........
chemo.
J8501.............. Oral aprepitant........... CH................ K................. 0868 ........... $4.99 ........... $1.00
J8510.............. Oral busulfan............. .................. K................. 7015 ........... $2.26 ........... $0.45
J8515.............. Cabergoline, oral 0.25mg.. .................. E................. ........... ........... ........... ........... ...........
J8520.............. Capecitabine, oral, 150 mg .................. K................. 7042 ........... $4.28 ........... $0.86
J8521.............. Capecitabine, oral, 500 mg CH................ K................. 0934 ........... $14.19 ........... $2.84
J8530.............. Cyclophosphamide oral 25 .................. N................. ........... ........... ........... ........... ...........
MG.
J8540.............. Oral dexamethasone........ .................. N................. ........... ........... ........... ........... ...........
J8560.............. Etoposide oral 50 MG...... .................. K................. 0802 ........... $29.46 ........... $5.89
J8565.............. Gefitinib oral............ .................. E................. ........... ........... ........... ........... ...........
J8597.............. Antiemetic drug oral NOS.. .................. N................. ........... ........... ........... ........... ...........
J8600.............. Melphalan oral 2 MG....... CH................ K................. 0882 ........... $4.14 ........... $0.83
J8610.............. Methotrexate oral 2.5 MG.. .................. N................. ........... ........... ........... ........... ...........
J8650.............. Nabilone oral............. .................. K................. 0808 ........... $16.80 ........... $3.36
J8700.............. Temozolomide.............. .................. K................. 1086 ........... $7.49 ........... $1.50
J8999.............. Oral prescription drug .................. B................. ........... ........... ........... ........... ...........
chemo.
J9000.............. Doxorubic hcl 10 MG vl CH................ N................. ........... ........... ........... ........... ...........
chemo.
J9001.............. Doxorubicin hcl liposome .................. K................. 7046 ........... $396.15 ........... $79.23
inj.
[[Page 67146]]
J9010.............. Alemtuzumab injection..... .................. K................. 9110 ........... $549.77 ........... $109.95
J9015.............. Aldesleukin/single use .................. K................. 0807 ........... $788.84 ........... $157.77
vial.
J9017.............. Arsenic trioxide.......... .................. K................. 9012 ........... $34.44 ........... $6.89
J9020.............. Asparaginase injection.... .................. K................. 0814 ........... $54.26 ........... $10.85
J9025.............. Azacitidine injection..... .................. K................. 1709 ........... $4.35 ........... $0.87
J9027.............. Clofarabine injection..... CH................ K................. 1710 ........... $114.41 ........... $22.88
J9031.............. Bcg live intravesical vac. .................. K................. 0809 ........... $113.75 ........... $22.75
J9035.............. Bevacizumab injection..... .................. K................. 9214 ........... $56.93 ........... $11.39
J9040.............. Bleomycin sulfate .................. K................. 0748 ........... $42.93 ........... $8.59
injection.
J9041.............. Bortezomib injection...... .................. K................. 9207 ........... $33.20 ........... $6.64
J9045.............. Carboplatin injection..... .................. K................. 0811 ........... $7.44 ........... $1.49
J9050.............. Carmus bischl nitro inj... .................. K................. 0812 ........... $152.24 ........... $30.45
J9055.............. Cetuximab injection....... .................. K................. 9215 ........... $49.43 ........... $9.89
J9060.............. Cisplatin 10 MG injection. .................. N................. ........... ........... ........... ........... ...........
J9062.............. Cisplatin 50 MG injection. CH................ N................. ........... ........... ........... ........... ...........
J9065.............. Inj cladribine per 1 MG... .................. K................. 0858 ........... $32.04 ........... $6.41
J9070.............. Cyclophosphamide 100 MG .................. N................. ........... ........... ........... ........... ...........
inj.
J9080.............. Cyclophosphamide 200 MG CH................ N................. ........... ........... ........... ........... ...........
inj.
J9090.............. Cyclophosphamide 500 MG CH................ N................. ........... ........... ........... ........... ...........
inj.
J9091.............. Cyclophosphamide 1.0 grm CH................ N................. ........... ........... ........... ........... ...........
inj.
J9092.............. Cyclophosphamide 2.0 grm CH................ N................. ........... ........... ........... ........... ...........
inj.
J9093.............. Cyclophosphamide CH................ N................. ........... ........... ........... ........... ...........
lyophilized.
J9094.............. Cyclophosphamide CH................ N................. ........... ........... ........... ........... ...........
lyophilized.
J9095.............. Cyclophosphamide CH................ N................. ........... ........... ........... ........... ...........
lyophilized.
J9096.............. Cyclophosphamide CH................ N................. ........... ........... ........... ........... ...........
lyophilized.
J9097.............. Cyclophosphamide CH................ N................. ........... ........... ........... ........... ...........
lyophilized.
J9098.............. Cytarabine liposome....... .................. K................. 1166 ........... $412.21 ........... $82.44
J9100.............. Cytarabine hcl 100 MG inj. .................. N................. ........... ........... ........... ........... ...........
J9110.............. Cytarabine hcl 500 MG inj. CH................ N................. ........... ........... ........... ........... ...........
J9120.............. Dactinomycin actinomycin d .................. K................. 0752 ........... $488.78 ........... $97.76
J9130.............. Dacarbazine 100 mg inj.... CH................ N................. ........... ........... ........... ........... ...........
J9140.............. Dacarbazine 200 MG inj.... CH................ N................. ........... ........... ........... ........... ...........
J9150.............. Daunorubicin.............. .................. K................. 0820 ........... $19.33 ........... $3.87
J9151.............. Daunorubicin citrate .................. K................. 0821 ........... $55.23 ........... $11.05
liposom.
J9160.............. Denileukin diftitox, 300 .................. K................. 1084 ........... $1,386.59 ........... $277.32
mcg.
J9165.............. Diethylstilbestrol .................. N................. ........... ........... ........... ........... ...........
injection.
J9170.............. Docetaxel................. .................. K................. 0823 ........... $310.85 ........... $62.17
J9175.............. Elliotts b solution per ml .................. N................. ........... ........... ........... ........... ...........
J9178.............. Inj, epirubicin hcl, 2 mg. .................. K................. 1167 ........... $19.79 ........... $3.96
J9181.............. Etoposide 10 MG inj....... .................. N................. ........... ........... ........... ........... ...........
J9182.............. Etoposide 100 MG inj...... CH................ N................. ........... ........... ........... ........... ...........
J9185.............. Fludarabine phosphate inj. .................. K................. 0842 ........... $226.67 ........... $45.33
J9190.............. Fluorouracil injection.... .................. N................. ........... ........... ........... ........... ...........
J9200.............. Floxuridine injection..... .................. K................. 0827 ........... $54.63 ........... $10.93
J9201.............. Gemcitabine HCl........... .................. K................. 0828 ........... $127.31 ........... $25.46
J9202.............. Goserelin acetate implant. .................. K................. 0810 ........... $192.29 ........... $38.46
J9206.............. Irinotecan injection...... .................. K................. 0830 ........... $124.61 ........... $24.92
J9208.............. Ifosfomide injection...... .................. K................. 0831 ........... $38.13 ........... $7.63
J9209.............. Mesna injection........... .................. K................. 0732 ........... $7.97 ........... $1.59
J9211.............. Idarubicin hcl injection.. .................. K................. 0832 ........... $302.42 ........... $60.48
J9212.............. Interferon alfacon-1...... .................. K................. 0912 ........... $4.62 ........... $0.92
J9213.............. Interferon alfa-2a inj.... .................. K................. 0834 ........... $41.37 ........... $8.27
J9214.............. Interferon alfa-2b inj.... .................. K................. 0836 ........... $13.92 ........... $2.78
J9215.............. Interferon alfa-n3 inj.... .................. K................. 0865 ........... $9.03 ........... $1.81
J9216.............. Interferon gamma 1-b inj.. .................. K................. 0838 ........... $306.66 ........... $61.33
J9217.............. Leuprolide acetate .................. K................. 9217 ........... $236.06 ........... $47.21
suspnsion.
J9218.............. Leuprolide acetate .................. K................. 0861 ........... $7.98 ........... $1.60
injeciton.
J9219.............. Leuprolide acetate implant .................. K................. 7051 ........... $1,648.41 ........... $329.68
J9225.............. Vantas implant............ .................. K................. 1711 ........... $1,412.46 ........... $282.49
J9226.............. Supprelin LA implant...... NI................ K................. 1142 ........... $14,700.00 ........... $2,940.00
J9230.............. Mechlorethamine hcl inj... .................. K................. 0751 ........... $143.08 ........... $28.62
J9245.............. Inj melphalan hydrochl 50 .................. K................. 0840 ........... $1,548.88 ........... $309.78
MG.
J9250.............. Methotrexate sodium inj... .................. N................. ........... ........... ........... ........... ...........
J9260.............. Methotrexate sodium inj... CH................ N................. ........... ........... ........... ........... ...........
J9261.............. Nelarabine injection...... .................. G................. 0825 ........... $86.84 ........... $17.37
J9263.............. Oxaliplatin............... .................. K................. 1738 ........... $9.15 ........... $1.83
J9264.............. Paclitaxel protein bound.. CH................ K................. 1712 ........... $8.79 ........... $1.76
J9265.............. Paclitaxel injection...... .................. K................. 0863 ........... $14.57 ........... $2.91
J9266.............. Pegaspargase/singl dose .................. K................. 0843 ........... $2,080.19 ........... $416.04
vial.
J9268.............. Pentostatin injection..... .................. K................. 0844 ........... $2,051.68 ........... $410.34
J9270.............. Plicamycin (mithramycin) CH................ K................. 1041 ........... $172.41 ........... $34.48
inj.
J9280.............. Mitomycin 5 MG inj........ .................. K................. 0862 ........... $14.39 ........... $2.88
J9290.............. Mitomycin 20 MG inj....... CH................ K................. 0941 ........... $57.56 ........... $11.51
J9291.............. Mitomycin 40 MG inj....... CH................ K................. 0942 ........... $115.11 ........... $23.02
J9293.............. Mitoxantrone hydrochl / 5 .................. K................. 0864 ........... $107.96 ........... $21.59
MG.
J9300.............. Gemtuzumab ozogamicin..... .................. K................. 9004 ........... $2,411.98 ........... $482.40
J9303.............. Panitumumab injection..... NI................ G................. 9235 ........... $83.15 ........... $16.63
J9305.............. Pemetrexed injection...... .................. K................. 9213 ........... $44.49 ........... $8.90
J9310.............. Rituximab cancer treatment .................. K................. 0849 ........... $504.40 ........... $100.88
J9320.............. Streptozocin injection.... .................. K................. 0850 ........... $146.93 ........... $29.39
[[Page 67147]]
J9340.............. Thiotepa injection........ .................. K................. 0851 ........... $41.12 ........... $8.22
J9350.............. Topotecan................. .................. K................. 0852 ........... $859.62 ........... $171.92
J9355.............. Trastuzumab............... .................. K................. 1613 ........... $58.51 ........... $11.70
J9357.............. Valrubicin, 200 mg........ .................. K................. 9167 ........... $77.96 ........... $15.59
J9360.............. Vinblastine sulfate inj... .................. N................. ........... ........... ........... ........... ...........
J9370.............. Vincristine sulfate 1 MG .................. N................. ........... ........... ........... ........... ...........
inj.
J9375.............. Vincristine sulfate 2 MG CH................ N................. ........... ........... ........... ........... ...........
inj.
J9380.............. Vincristine sulfate 5 MG CH................ N................. ........... ........... ........... ........... ...........
inj.
J9390.............. Vinorelbine tartrate/10 mg .................. K................. 0855 ........... $21.41 ........... $4.28
J9395.............. Injection, Fulvestrant.... .................. K................. 9120 ........... $80.60 ........... $16.12
J9600.............. Porfimer sodium........... .................. K................. 0856 ........... $2,532.53 ........... $506.51
J9999.............. Chemotherapy drug......... .................. N................. ........... ........... ........... ........... ...........
K0001.............. Standard wheelchair....... .................. Y................. ........... ........... ........... ........... ...........
K0002.............. Stnd hemi (low seat) .................. Y................. ........... ........... ........... ........... ...........
whlchr.
K0003.............. Lightweight wheelchair.... .................. Y................. ........... ........... ........... ........... ...........
K0004.............. High strength ltwt whlchr. .................. Y................. ........... ........... ........... ........... ...........
K0005.............. Ultralightweight .................. Y................. ........... ........... ........... ........... ...........
wheelchair.
K0006.............. Heavy duty wheelchair..... .................. Y................. ........... ........... ........... ........... ...........
K0007.............. Extra heavy duty .................. Y................. ........... ........... ........... ........... ...........
wheelchair.
K0009.............. Other manual wheelchair/ .................. Y................. ........... ........... ........... ........... ...........
base.
K0010.............. Stnd wt frame power whlchr .................. Y................. ........... ........... ........... ........... ...........
K0011.............. Stnd wt pwr whlchr w .................. Y................. ........... ........... ........... ........... ...........
control.
K0012.............. Ltwt portbl power whlchr.. .................. Y................. ........... ........... ........... ........... ...........
K0014.............. Other power whlchr base... .................. Y................. ........... ........... ........... ........... ...........
K0015.............. Detach non-adjus hght .................. Y................. ........... ........... ........... ........... ...........
armrst.
K0017.............. Detach adjust armrest base .................. Y................. ........... ........... ........... ........... ...........
K0018.............. Detach adjust armrst upper .................. Y................. ........... ........... ........... ........... ...........
K0019.............. Arm pad each.............. .................. Y................. ........... ........... ........... ........... ...........
K0020.............. Fixed adjust armrest pair. .................. Y................. ........... ........... ........... ........... ...........
K0037.............. High mount flip-up .................. Y................. ........... ........... ........... ........... ...........
footrest.
K0038.............. Leg strap each............ .................. Y................. ........... ........... ........... ........... ...........
K0039.............. Leg strap h style each.... .................. Y................. ........... ........... ........... ........... ...........
K0040.............. Adjustable angle footplate .................. Y................. ........... ........... ........... ........... ...........
K0041.............. Large size footplate each. .................. Y................. ........... ........... ........... ........... ...........
K0042.............. Standard size footplate .................. Y................. ........... ........... ........... ........... ...........
each.
K0043.............. Ftrst lower extension tube .................. Y................. ........... ........... ........... ........... ...........
K0044.............. Ftrst upper hanger bracket .................. Y................. ........... ........... ........... ........... ...........
K0045.............. Footrest complete assembly .................. Y................. ........... ........... ........... ........... ...........
K0046.............. Elevat legrst low .................. Y................. ........... ........... ........... ........... ...........
extension.
K0047.............. Elevat legrst up hangr .................. Y................. ........... ........... ........... ........... ...........
brack.
K0050.............. Ratchet assembly.......... .................. Y................. ........... ........... ........... ........... ...........
K0051.............. Cam relese assem ftrst/ .................. Y................. ........... ........... ........... ........... ...........
lgrst.
K0052.............. Swingaway detach footrest. .................. Y................. ........... ........... ........... ........... ...........
K0053.............. Elevate footrest .................. Y................. ........... ........... ........... ........... ...........
articulate.
K0056.............. Seat ht <17 or >=21 ltwt .................. Y................. ........... ........... ........... ........... ...........
wc.
K0065.............. Spoke protectors.......... .................. Y................. ........... ........... ........... ........... ...........
K0069.............. Rear whl complete solid .................. Y................. ........... ........... ........... ........... ...........
tire.
K0070.............. Rear whl compl pneum tire. .................. Y................. ........... ........... ........... ........... ...........
K0071.............. Front castr compl pneum .................. Y................. ........... ........... ........... ........... ...........
tire.
K0072.............. Frnt cstr cmpl sem-pneum .................. Y................. ........... ........... ........... ........... ...........
tir.
K0073.............. Caster pin lock each...... .................. Y................. ........... ........... ........... ........... ...........
K0077.............. Front caster assem .................. Y................. ........... ........... ........... ........... ...........
complete.
K0098.............. Drive belt power .................. Y................. ........... ........... ........... ........... ...........
wheelchair.
K0105.............. Iv hanger................. .................. Y................. ........... ........... ........... ........... ...........
K0108.............. W/c component-accessory .................. Y................. ........... ........... ........... ........... ...........
NOS.
K0195.............. Elevating whlchair leg .................. Y................. ........... ........... ........... ........... ...........
rests.
K0455.............. Pump uninterrupted .................. Y................. ........... ........... ........... ........... ...........
infusion.
K0462.............. Temporary replacement .................. Y................. ........... ........... ........... ........... ...........
eqpmnt.
K0552.............. Supply/ext inf pump syr .................. Y................. ........... ........... ........... ........... ...........
type.
K0553.............. Combination oral/nasal CH................ D................. ........... ........... ........... ........... ...........
mask.
K0554.............. Repl oral cushion combo CH................ D................. ........... ........... ........... ........... ...........
mask.
K0555.............. Repl nasal pillow comb CH................ D................. ........... ........... ........... ........... ...........
mask.
K0601.............. Repl batt silver oxide 1.5 .................. Y................. ........... ........... ........... ........... ...........
v.
K0602.............. Repl batt silver oxide 3 v .................. Y................. ........... ........... ........... ........... ...........
K0603.............. Repl batt alkaline 1.5 v.. .................. Y................. ........... ........... ........... ........... ...........
K0604.............. Repl batt lithium 3.6 v... .................. Y................. ........... ........... ........... ........... ...........
K0605.............. Repl batt lithium 4.5 v... .................. Y................. ........... ........... ........... ........... ...........
K0606.............. AED garment w elec .................. Y................. ........... ........... ........... ........... ...........
analysis.
K0607.............. Repl batt for AED......... .................. Y................. ........... ........... ........... ........... ...........
K0608.............. Repl garment for AED...... .................. Y................. ........... ........... ........... ........... ...........
K0609.............. Repl electrode for AED.... .................. Y................. ........... ........... ........... ........... ...........
K0669.............. Seat/back cus no sadmerc .................. Y................. ........... ........... ........... ........... ...........
ver.
K0730.............. Ctrl dose inh drug deliv .................. Y................. ........... ........... ........... ........... ...........
sys.
K0733.............. 12-24hr sealed lead acid.. .................. Y................. ........... ........... ........... ........... ...........
K0734.............. Adj skin pro w/c cus .................. Y................. ........... ........... ........... ........... ...........
wd<22in.
K0735.............. Adj skin pro wc cus .................. Y................. ........... ........... ........... ........... ...........
wd>=22in.
K0736.............. Adj skin pro/pos wc .................. Y................. ........... ........... ........... ........... ...........
cus<22in.
K0737.............. Adj skin pro/pos wc .................. Y................. ........... ........... ........... ........... ...........
cus>=22''.
K0738.............. Portable gas oxygen system .................. Y................. ........... ........... ........... ........... ...........
K0800.............. POV group 1 std up to .................. Y................. ........... ........... ........... ........... ...........
300lbs.
[[Page 67148]]
K0801.............. POV group 1 hd 301-450 lbs .................. Y................. ........... ........... ........... ........... ...........
K0802.............. POV group 1 vhd 451-600 .................. Y................. ........... ........... ........... ........... ...........
lbs.
K0806.............. POV group 2 std up to .................. Y................. ........... ........... ........... ........... ...........
300lbs.
K0807.............. POV group 2 hd 301-450 lbs .................. Y................. ........... ........... ........... ........... ...........
K0808.............. POV group 2 vhd 451-600 .................. Y................. ........... ........... ........... ........... ...........
lbs.
K0812.............. Power operated vehicle NOC .................. Y................. ........... ........... ........... ........... ...........
K0813.............. PWC gp 1 std port seat/ .................. Y................. ........... ........... ........... ........... ...........
back.
K0814.............. PWC gp 1 std port cap .................. Y................. ........... ........... ........... ........... ...........
chair.
K0815.............. PWC gp 1 std seat/back.... .................. Y................. ........... ........... ........... ........... ...........
K0816.............. PWC gp 1 std cap chair.... .................. Y................. ........... ........... ........... ........... ...........
K0820.............. PWC gp 2 std port seat/ .................. Y................. ........... ........... ........... ........... ...........
back.
K0821.............. PWC gp 2 std port cap .................. Y................. ........... ........... ........... ........... ...........
chair.
K0822.............. PWC gp 2 std seat/back.... .................. Y................. ........... ........... ........... ........... ...........
K0823.............. PWC gp 2 std cap chair.... .................. Y................. ........... ........... ........... ........... ...........
K0824.............. PWC gp 2 hd seat/back..... .................. Y................. ........... ........... ........... ........... ...........
K0825.............. PWC gp 2 hd cap chair..... .................. Y................. ........... ........... ........... ........... ...........
K0826.............. PWC gp 2 vhd seat/back.... .................. Y................. ........... ........... ........... ........... ...........
K0827.............. PWC gp vhd cap chair...... .................. Y................. ........... ........... ........... ........... ...........
K0828.............. PWC gp 2 xtra hd seat/back .................. Y................. ........... ........... ........... ........... ...........
K0829.............. PWC gp 2 xtra hd cap chair .................. Y................. ........... ........... ........... ........... ...........
K0830.............. PWC gp2 std seat elevate s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0831.............. PWC gp2 std seat elevate .................. Y................. ........... ........... ........... ........... ...........
cap.
K0835.............. PWC gp2 std sing pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0836.............. PWC gp2 std sing pow opt .................. Y................. ........... ........... ........... ........... ...........
cap.
K0837.............. PWC gp 2 hd sing pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0838.............. PWC gp 2 hd sing pow opt .................. Y................. ........... ........... ........... ........... ...........
cap.
K0839.............. PWC gp2 vhd sing pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0840.............. PWC gp2 xhd sing pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0841.............. PWC gp2 std mult pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0842.............. PWC gp2 std mult pow opt .................. Y................. ........... ........... ........... ........... ...........
cap.
K0843.............. PWC gp2 hd mult pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0848.............. PWC gp 3 std seat/back.... .................. Y................. ........... ........... ........... ........... ...........
K0849.............. PWC gp 3 std cap chair.... .................. Y................. ........... ........... ........... ........... ...........
K0850.............. PWC gp 3 hd seat/back..... .................. Y................. ........... ........... ........... ........... ...........
K0851.............. PWC gp 3 hd cap chair..... .................. Y................. ........... ........... ........... ........... ...........
K0852.............. PWC gp 3 vhd seat/back.... .................. Y................. ........... ........... ........... ........... ...........
K0853.............. PWC gp 3 vhd cap chair.... .................. Y................. ........... ........... ........... ........... ...........
K0854.............. PWC gp 3 xhd seat/back.... .................. Y................. ........... ........... ........... ........... ...........
K0855.............. PWC gp 3 xhd cap chair.... .................. Y................. ........... ........... ........... ........... ...........
K0856.............. PWC gp3 std sing pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0857.............. PWC gp3 std sing pow opt .................. Y................. ........... ........... ........... ........... ...........
cap.
K0858.............. PWC gp3 hd sing pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0859.............. PWC gp3 hd sing pow opt .................. Y................. ........... ........... ........... ........... ...........
cap.
K0860.............. PWC gp3 vhd sing pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0861.............. PWC gp3 std mult pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0862.............. PWC gp3 hd mult pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0863.............. PWC gp3 vhd mult pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0864.............. PWC gp3 xhd mult pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0868.............. PWC gp 4 std seat/back.... .................. Y................. ........... ........... ........... ........... ...........
K0869.............. PWC gp 4 std cap chair.... .................. Y................. ........... ........... ........... ........... ...........
K0870.............. PWC gp 4 hd seat/back..... .................. Y................. ........... ........... ........... ........... ...........
K0871.............. PWC gp 4 vhd seat/back.... .................. Y................. ........... ........... ........... ........... ...........
K0877.............. PWC gp4 std sing pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0878.............. PWC gp4 std sing pow opt .................. Y................. ........... ........... ........... ........... ...........
cap.
K0879.............. PWC gp4 hd sing pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0880.............. PWC gp4 vhd sing pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0884.............. PWC gp4 std mult pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0885.............. PWC gp4 std mult pow opt .................. Y................. ........... ........... ........... ........... ...........
cap.
K0886.............. PWC gp4 hd mult pow s/b... .................. Y................. ........... ........... ........... ........... ...........
K0890.............. PWC gp5 ped sing pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0891.............. PWC gp5 ped mult pow opt s/ .................. Y................. ........... ........... ........... ........... ...........
b.
K0898.............. Power wheelchair NOC...... .................. Y................. ........... ........... ........... ........... ...........
K0899.............. Pow mobil dev no SADMERC.. .................. Y................. ........... ........... ........... ........... ...........
L0112.............. Cranial cervical orthosis. .................. A................. ........... ........... ........... ........... ...........
L0120.............. Cerv flexible non- .................. A................. ........... ........... ........... ........... ...........
adjustable.
L0130.............. Flex thermoplastic collar .................. A................. ........... ........... ........... ........... ...........
mo.
L0140.............. Cervical semi-rigid .................. A................. ........... ........... ........... ........... ...........
adjustab.
L0150.............. Cerv semi-rig adj molded .................. A................. ........... ........... ........... ........... ...........
chn.
L0160.............. Cerv semi-rig wire occ/ .................. A................. ........... ........... ........... ........... ...........
mand.
L0170.............. Cervical collar molded to .................. A................. ........... ........... ........... ........... ...........
pt.
L0172.............. Cerv col thermplas foam 2 .................. A................. ........... ........... ........... ........... ...........
pi.
L0174.............. Cerv col foam 2 piece w .................. A................. ........... ........... ........... ........... ...........
thor.
L0180.............. Cer post col occ/man sup .................. A................. ........... ........... ........... ........... ...........
adj.
L0190.............. Cerv collar supp adj cerv .................. A................. ........... ........... ........... ........... ...........
ba.
L0200.............. Cerv col supp adj bar & .................. A................. ........... ........... ........... ........... ...........
thor.
L0210.............. Thoracic rib belt......... .................. A................. ........... ........... ........... ........... ...........
L0220.............. Thor rib belt custom .................. A................. ........... ........... ........... ........... ...........
fabrica.
L0430.............. Dewall posture protector.. .................. A................. ........... ........... ........... ........... ...........
L0450.............. TLSO flex prefab thoracic. .................. A................. ........... ........... ........... ........... ...........
L0452.............. tlso flex custom fab .................. A................. ........... ........... ........... ........... ...........
thoraci.
[[Page 67149]]
L0454.............. TLSO flex prefab sacrococ- .................. A................. ........... ........... ........... ........... ...........
T9.
L0456.............. TLSO flex prefab.......... .................. A................. ........... ........... ........... ........... ...........
L0458.............. TLSO 2Mod symphis-xipho .................. A................. ........... ........... ........... ........... ...........
pre.
L0460.............. TLSO2Mod symphysis-stern .................. A................. ........... ........... ........... ........... ...........
pre.
L0462.............. TLSO 3Mod sacro-scap pre.. .................. A................. ........... ........... ........... ........... ...........
L0464.............. TLSO 4Mod sacro-scap pre.. .................. A................. ........... ........... ........... ........... ...........
L0466.............. TLSO rigid frame pre soft .................. A................. ........... ........... ........... ........... ...........
ap.
L0468.............. TLSO rigid frame prefab .................. A................. ........... ........... ........... ........... ...........
pelv.
L0470.............. TLSO rigid frame pre .................. A................. ........... ........... ........... ........... ...........
subclav.
L0472.............. TLSO rigid frame hyperex .................. A................. ........... ........... ........... ........... ...........
pre.
L0480.............. TLSO rigid plastic custom .................. A................. ........... ........... ........... ........... ...........
fa.
L0482.............. TLSO rigid lined custom .................. A................. ........... ........... ........... ........... ...........
fab.
L0484.............. TLSO rigid plastic cust .................. A................. ........... ........... ........... ........... ...........
fab.
L0486.............. TLSO rigidlined cust fab .................. A................. ........... ........... ........... ........... ...........
two.
L0488.............. TLSO rigid lined pre one .................. A................. ........... ........... ........... ........... ...........
pie.
L0490.............. TLSO rigid plastic pre one .................. A................. ........... ........... ........... ........... ...........
L0491.............. TLSO 2 piece rigid shell.. .................. A................. ........... ........... ........... ........... ...........
L0492.............. TLSO 3 piece rigid shell.. .................. A................. ........... ........... ........... ........... ...........
L0621.............. SIO flex pelvisacral .................. A................. ........... ........... ........... ........... ...........
prefab.
L0622.............. SIO flex pelvisacral .................. A................. ........... ........... ........... ........... ...........
custom.
L0623.............. SIO panel prefab.......... .................. A................. ........... ........... ........... ........... ...........
L0624.............. SIO panel custom.......... .................. A................. ........... ........... ........... ........... ...........
L0625.............. LO flexibl L1-below L5 pre .................. A................. ........... ........... ........... ........... ...........
L0626.............. LO sag stays/panels pre- .................. A................. ........... ........... ........... ........... ...........
fab.
L0627.............. LO sagitt rigid panel .................. A................. ........... ........... ........... ........... ...........
prefab.
L0628.............. LO flex w/o rigid stays .................. A................. ........... ........... ........... ........... ...........
pre.
L0629.............. LSO flex w/rigid stays .................. A................. ........... ........... ........... ........... ...........
cust.
L0630.............. LSO post rigid panel pre.. .................. A................. ........... ........... ........... ........... ...........
L0631.............. LSO sag-coro rigid frame .................. A................. ........... ........... ........... ........... ...........
pre.
L0632.............. LSO sag rigid frame cust.. .................. A................. ........... ........... ........... ........... ...........
L0633.............. LSO flexion control prefab .................. A................. ........... ........... ........... ........... ...........
L0634.............. LSO flexion control custom .................. A................. ........... ........... ........... ........... ...........
L0635.............. LSO sagit rigid panel .................. A................. ........... ........... ........... ........... ...........
prefab.
L0636.............. LSO sagittal rigid panel .................. A................. ........... ........... ........... ........... ...........
cus.
L0637.............. LSO sag-coronal panel .................. A................. ........... ........... ........... ........... ...........
prefab.
L0638.............. LSO sag-coronal panel .................. A................. ........... ........... ........... ........... ...........
custom.
L0639.............. LSO s/c shell/panel prefab .................. A................. ........... ........... ........... ........... ...........
L0640.............. LSO s/c shell/panel custom .................. A................. ........... ........... ........... ........... ...........
L0700.............. Ctlso a-p-l control molded .................. A................. ........... ........... ........... ........... ...........
L0710.............. Ctlso a-p-l control w/ .................. A................. ........... ........... ........... ........... ...........
inter.
L0810.............. Halo cervical into jckt .................. A................. ........... ........... ........... ........... ...........
vest.
L0820.............. Halo cervical into body .................. A................. ........... ........... ........... ........... ...........
jack.
L0830.............. Halo cerv into milwaukee .................. A................. ........... ........... ........... ........... ...........
typ.
L0859.............. MRI compatible system..... .................. A................. ........... ........... ........... ........... ...........
L0861.............. Halo repl liner/interface. .................. A................. ........... ........... ........... ........... ...........
L0960.............. Post surgical support pads CH................ D................. ........... ........... ........... ........... ...........
L0970.............. Tlso corset front......... .................. A................. ........... ........... ........... ........... ...........
L0972.............. Lso corset front.......... .................. A................. ........... ........... ........... ........... ...........
L0974.............. Tlso full corset.......... .................. A................. ........... ........... ........... ........... ...........
L0976.............. Lso full corset........... .................. A................. ........... ........... ........... ........... ...........
L0978.............. Axillary crutch extension. .................. A................. ........... ........... ........... ........... ...........
L0980.............. Peroneal straps pair...... .................. A................. ........... ........... ........... ........... ...........
L0982.............. Stocking supp grips set of .................. A................. ........... ........... ........... ........... ...........
f.
L0984.............. Protective body sock each. .................. A................. ........... ........... ........... ........... ...........
L0999.............. Add to spinal orthosis NOS .................. A................. ........... ........... ........... ........... ...........
L1000.............. Ctlso milwauke initial .................. A................. ........... ........... ........... ........... ...........
model.
L1001.............. CTLSO infant immobilizer.. .................. A................. ........... ........... ........... ........... ...........
L1005.............. Tension based scoliosis .................. A................. ........... ........... ........... ........... ...........
orth.
L1010.............. Ctlso axilla sling........ .................. A................. ........... ........... ........... ........... ...........
L1020.............. Kyphosis pad.............. .................. A................. ........... ........... ........... ........... ...........
L1025.............. Kyphosis pad floating..... .................. A................. ........... ........... ........... ........... ...........
L1030.............. Lumbar bolster pad........ .................. A................. ........... ........... ........... ........... ...........
L1040.............. Lumbar or lumbar rib pad.. .................. A................. ........... ........... ........... ........... ...........
L1050.............. Sternal pad............... .................. A................. ........... ........... ........... ........... ...........
L1060.............. Thoracic pad.............. .................. A................. ........... ........... ........... ........... ...........
L1070.............. Trapezius sling........... .................. A................. ........... ........... ........... ........... ...........
L1080.............. Outrigger................. .................. A................. ........... ........... ........... ........... ...........
L1085.............. Outrigger bil w/ vert .................. A................. ........... ........... ........... ........... ...........
extens.
L1090.............. Lumbar sling.............. .................. A................. ........... ........... ........... ........... ...........
L1100.............. Ring flange plastic/ .................. A................. ........... ........... ........... ........... ...........
leather.
L1110.............. Ring flange plas/leather .................. A................. ........... ........... ........... ........... ...........
mol.
L1120.............. Covers for upright each... .................. A................. ........... ........... ........... ........... ...........
L1200.............. Furnsh initial orthosis .................. A................. ........... ........... ........... ........... ...........
only.
L1210.............. Lateral thoracic extension .................. A................. ........... ........... ........... ........... ...........
L1220.............. Anterior thoracic .................. A................. ........... ........... ........... ........... ...........
extension.
L1230.............. Milwaukee type .................. A................. ........... ........... ........... ........... ...........
superstructur.
L1240.............. Lumbar derotation pad..... .................. A................. ........... ........... ........... ........... ...........
L1250.............. Anterior asis pad......... .................. A................. ........... ........... ........... ........... ...........
L1260.............. Anterior thoracic .................. A................. ........... ........... ........... ........... ...........
derotation.
L1270.............. Abdominal pad............. .................. A................. ........... ........... ........... ........... ...........
[[Page 67150]]
L1280.............. Rib gusset (elastic) each. .................. A................. ........... ........... ........... ........... ...........
L1290.............. Lateral trochanteric pad.. .................. A................. ........... ........... ........... ........... ...........
L1300.............. Body jacket mold to .................. A................. ........... ........... ........... ........... ...........
patient.
L1310.............. Post-operative body jacket .................. A................. ........... ........... ........... ........... ...........
L1499.............. Spinal orthosis NOS....... .................. A................. ........... ........... ........... ........... ...........
L1500.............. Thkao mobility frame...... .................. A................. ........... ........... ........... ........... ...........
L1510.............. Thkao standing frame...... .................. A................. ........... ........... ........... ........... ...........
L1520.............. Thkao swivel walker....... .................. A................. ........... ........... ........... ........... ...........
L1600.............. Abduct hip flex frejka w .................. A................. ........... ........... ........... ........... ...........
cvr.
L1610.............. Abduct hip flex frejka .................. A................. ........... ........... ........... ........... ...........
covr.
L1620.............. Abduct hip flex pavlik .................. A................. ........... ........... ........... ........... ...........
harne.
L1630.............. Abduct control hip semi- .................. A................. ........... ........... ........... ........... ...........
flex.
L1640.............. Pelv band/spread bar thigh .................. A................. ........... ........... ........... ........... ...........
c.
L1650.............. HO abduction hip .................. A................. ........... ........... ........... ........... ...........
adjustable.
L1652.............. HO bi thighcuffs w sprdr .................. A................. ........... ........... ........... ........... ...........
bar.
L1660.............. HO abduction static .................. A................. ........... ........... ........... ........... ...........
plastic.
L1680.............. Pelvic & hip control thigh .................. A................. ........... ........... ........... ........... ...........
c.
L1685.............. Post-op hip abduct custom .................. A................. ........... ........... ........... ........... ...........
fa.
L1686.............. HO post-op hip abduction.. .................. A................. ........... ........... ........... ........... ...........
L1690.............. Combination bilateral HO.. .................. A................. ........... ........... ........... ........... ...........
L1700.............. Leg perthes orth toronto .................. A................. ........... ........... ........... ........... ...........
typ.
L1710.............. Legg perthes orth .................. A................. ........... ........... ........... ........... ...........
newington.
L1720.............. Legg perthes orthosis .................. A................. ........... ........... ........... ........... ...........
trilat.
L1730.............. Legg perthes orth scottish .................. A................. ........... ........... ........... ........... ...........
r.
L1755.............. Legg perthes patten bottom .................. A................. ........... ........... ........... ........... ...........
t.
L1800.............. Knee orthoses elas w stays .................. A................. ........... ........... ........... ........... ...........
L1810.............. Ko elastic with joints.... .................. A................. ........... ........... ........... ........... ...........
L1815.............. Elastic with condylar pads .................. A................. ........... ........... ........... ........... ...........
L1820.............. Ko elas w/ condyle pads & .................. A................. ........... ........... ........... ........... ...........
jo.
L1825.............. Ko elastic knee cap....... .................. A................. ........... ........... ........... ........... ...........
L1830.............. Ko immobilizer canvas .................. A................. ........... ........... ........... ........... ...........
longit.
L1831.............. Knee orth pos locking .................. A................. ........... ........... ........... ........... ...........
joint.
L1832.............. KO adj jnt pos rigid .................. A................. ........... ........... ........... ........... ...........
support.
L1834.............. Ko w/0 joint rigid molded .................. A................. ........... ........... ........... ........... ...........
to.
L1836.............. Rigid KO wo joints........ .................. A................. ........... ........... ........... ........... ...........
L1840.............. Ko derot ant cruciate .................. A................. ........... ........... ........... ........... ...........
custom.
L1843.............. KO single upright custom .................. A................. ........... ........... ........... ........... ...........
fit.
L1844.............. Ko w/adj jt rot cntrl .................. A................. ........... ........... ........... ........... ...........
molded.
L1845.............. Ko w/ adj flex/ext rotat .................. A................. ........... ........... ........... ........... ...........
cus.
L1846.............. Ko w adj flex/ext rotat .................. A................. ........... ........... ........... ........... ...........
mold.
L1847.............. KO adjustable w air .................. A................. ........... ........... ........... ........... ...........
chambers.
L1850.............. Ko swedish type........... .................. A................. ........... ........... ........... ........... ...........
L1855.............. Ko plas doub upright jnt CH................ D................. ........... ........... ........... ........... ...........
mol.
L1858.............. Ko polycentric pneumatic CH................ D................. ........... ........... ........... ........... ...........
pad.
L1860.............. Ko supracondylar socket .................. A................. ........... ........... ........... ........... ...........
mold.
L1870.............. Ko doub upright lacers CH................ D................. ........... ........... ........... ........... ...........
molde.
L1880.............. Ko doub upright cuffs/ CH................ D................. ........... ........... ........... ........... ...........
lacers.
L1900.............. Afo sprng wir drsflx calf .................. A................. ........... ........... ........... ........... ...........
bd.
L1901.............. Prefab ankle orthosis..... .................. A................. ........... ........... ........... ........... ...........
L1902.............. Afo ankle gauntlet........ .................. A................. ........... ........... ........... ........... ...........
L1904.............. Afo molded ankle gauntlet. .................. A................. ........... ........... ........... ........... ...........
L1906.............. Afo multiligamentus ankle .................. A................. ........... ........... ........... ........... ...........
su.
L1907.............. AFO supramalleolar custom. .................. A................. ........... ........... ........... ........... ...........
L1910.............. Afo sing bar clasp attach .................. A................. ........... ........... ........... ........... ...........
sh.
L1920.............. Afo sing upright w/ adjust .................. A................. ........... ........... ........... ........... ...........
s.
L1930.............. Afo plastic............... .................. A................. ........... ........... ........... ........... ...........
L1932.............. Afo rig ant tib prefab TCF/ .................. A................. ........... ........... ........... ........... ...........
=.
L1940.............. Afo molded to patient .................. A................. ........... ........... ........... ........... ...........
plasti.
L1945.............. Afo molded plas rig ant .................. A................. ........... ........... ........... ........... ...........
tib.
L1950.............. Afo spiral molded to pt .................. A................. ........... ........... ........... ........... ...........
plas.
L1951.............. AFO spiral prefabricated.. .................. A................. ........... ........... ........... ........... ...........
L1960.............. Afo pos solid ank plastic .................. A................. ........... ........... ........... ........... ...........
mo.
L1970.............. Afo plastic molded w/ankle .................. A................. ........... ........... ........... ........... ...........
j.
L1971.............. AFO w/ankle joint, prefab. .................. A................. ........... ........... ........... ........... ...........
L1980.............. Afo sing solid stirrup .................. A................. ........... ........... ........... ........... ...........
calf.
L1990.............. Afo doub solid stirrup .................. A................. ........... ........... ........... ........... ...........
calf.
L2000.............. Kafo sing fre stirr thi/ .................. A................. ........... ........... ........... ........... ...........
calf.
L2005.............. KAFO sng/dbl mechanical .................. A................. ........... ........... ........... ........... ...........
act.
L2010.............. Kafo sng solid stirrup w/o .................. A................. ........... ........... ........... ........... ...........
j.
L2020.............. Kafo dbl solid stirrup .................. A................. ........... ........... ........... ........... ...........
band/.
L2030.............. Kafo dbl solid stirrup w/o .................. A................. ........... ........... ........... ........... ...........
j.
L2034.............. KAFO pla sin up w/wo k/a .................. A................. ........... ........... ........... ........... ...........
cus.
L2035.............. KAFO plastic pediatric .................. A................. ........... ........... ........... ........... ...........
size.
L2036.............. Kafo plas doub free knee .................. A................. ........... ........... ........... ........... ...........
mol.
L2037.............. Kafo plas sing free knee .................. A................. ........... ........... ........... ........... ...........
mol.
L2038.............. Kafo w/o joint multi-axis .................. A................. ........... ........... ........... ........... ...........
an.
L2040.............. Hkafo torsion bil rot .................. A................. ........... ........... ........... ........... ...........
straps.
L2050.............. Hkafo torsion cable hip .................. A................. ........... ........... ........... ........... ...........
pelv.
L2060.............. Hkafo torsion ball bearing .................. A................. ........... ........... ........... ........... ...........
j.
L2070.............. Hkafo torsion unilat rot .................. A................. ........... ........... ........... ........... ...........
str.
[[Page 67151]]
L2080.............. Hkafo unilat torsion cable .................. A................. ........... ........... ........... ........... ...........
L2090.............. Hkafo unilat torsion ball .................. A................. ........... ........... ........... ........... ...........
br.
L2106.............. Afo tib fx cast plaster .................. A................. ........... ........... ........... ........... ...........
mold.
L2108.............. Afo tib fx cast molded to .................. A................. ........... ........... ........... ........... ...........
pt.
L2112.............. Afo tibial fracture soft.. .................. A................. ........... ........... ........... ........... ...........
L2114.............. Afo tib fx semi-rigid..... .................. A................. ........... ........... ........... ........... ...........
L2116.............. Afo tibial fracture rigid. .................. A................. ........... ........... ........... ........... ...........
L2126.............. Kafo fem fx cast .................. A................. ........... ........... ........... ........... ...........
thermoplas.
L2128.............. Kafo fem fx cast molded to .................. A................. ........... ........... ........... ........... ...........
p.
L2132.............. Kafo femoral fx cast soft. .................. A................. ........... ........... ........... ........... ...........
L2134.............. Kafo fem fx cast semi- .................. A................. ........... ........... ........... ........... ...........
rigid.
L2136.............. Kafo femoral fx cast rigid .................. A................. ........... ........... ........... ........... ...........
L2180.............. Plas shoe insert w ank .................. A................. ........... ........... ........... ........... ...........
joint.
L2182.............. Drop lock knee............ .................. A................. ........... ........... ........... ........... ...........
L2184.............. Limited motion knee joint. .................. A................. ........... ........... ........... ........... ...........
L2186.............. Adj motion knee jnt lerman .................. A................. ........... ........... ........... ........... ...........
t.
L2188.............. Quadrilateral brim........ .................. A................. ........... ........... ........... ........... ...........
L2190.............. Waist belt................ .................. A................. ........... ........... ........... ........... ...........
L2192.............. Pelvic band & belt thigh .................. A................. ........... ........... ........... ........... ...........
fla.
L2200.............. Limited ankle motion ea .................. A................. ........... ........... ........... ........... ...........
jnt.
L2210.............. Dorsiflexion assist each .................. A................. ........... ........... ........... ........... ...........
joi.
L2220.............. Dorsi & plantar flex ass/ .................. A................. ........... ........... ........... ........... ...........
res.
L2230.............. Split flat caliper stirr & .................. A................. ........... ........... ........... ........... ...........
p.
L2232.............. Rocker bottom, contact AFO .................. A................. ........... ........... ........... ........... ...........
L2240.............. Round caliper and plate .................. A................. ........... ........... ........... ........... ...........
atta.
L2250.............. Foot plate molded stirrup .................. A................. ........... ........... ........... ........... ...........
at.
L2260.............. Reinforced solid stirrup.. .................. A................. ........... ........... ........... ........... ...........
L2265.............. Long tongue stirrup....... .................. A................. ........... ........... ........... ........... ...........
L2270.............. Varus/valgus strap padded/ .................. A................. ........... ........... ........... ........... ...........
li.
L2275.............. Plastic mod low ext pad/ .................. A................. ........... ........... ........... ........... ...........
line.
L2280.............. Molded inner boot......... .................. A................. ........... ........... ........... ........... ...........
L2300.............. Abduction bar jointed .................. A................. ........... ........... ........... ........... ...........
adjust.
L2310.............. Abduction bar-straight.... .................. A................. ........... ........... ........... ........... ...........
L2320.............. Non-molded lacer.......... .................. A................. ........... ........... ........... ........... ...........
L2330.............. Lacer molded to patient .................. A................. ........... ........... ........... ........... ...........
mode.
L2335.............. Anterior swing band....... .................. A................. ........... ........... ........... ........... ...........
L2340.............. Pre-tibial shell molded to .................. A................. ........... ........... ........... ........... ...........
p.
L2350.............. Prosthetic type socket .................. A................. ........... ........... ........... ........... ...........
molde.
L2360.............. Extended steel shank...... .................. A................. ........... ........... ........... ........... ...........
L2370.............. Patten bottom............. .................. A................. ........... ........... ........... ........... ...........
L2375.............. Torsion ank & half solid .................. A................. ........... ........... ........... ........... ...........
sti.
L2380.............. Torsion straight knee .................. A................. ........... ........... ........... ........... ...........
joint.
L2385.............. Straight knee joint heavy .................. A................. ........... ........... ........... ........... ...........
du.
L2387.............. Add LE poly knee custom .................. A................. ........... ........... ........... ........... ...........
KAFO.
L2390.............. Offset knee joint each.... .................. A................. ........... ........... ........... ........... ...........
L2395.............. Offset knee joint heavy .................. A................. ........... ........... ........... ........... ...........
duty.
L2397.............. Suspension sleeve lower .................. A................. ........... ........... ........... ........... ...........
ext.
L2405.............. Knee joint drop lock ea .................. A................. ........... ........... ........... ........... ...........
jnt.
L2415.............. Knee joint cam lock each .................. A................. ........... ........... ........... ........... ...........
joi.
L2425.............. Knee disc/dial lock/adj .................. A................. ........... ........... ........... ........... ...........
flex.
L2430.............. Knee jnt ratchet lock ea .................. A................. ........... ........... ........... ........... ...........
jnt.
L2492.............. Knee lift loop drop lock .................. A................. ........... ........... ........... ........... ...........
rin.
L2500.............. Thi/glut/ischia wgt .................. A................. ........... ........... ........... ........... ...........
bearing.
L2510.............. Th/wght bear quad-lat brim .................. A................. ........... ........... ........... ........... ...........
m.
L2520.............. Th/wght bear quad-lat brim .................. A................. ........... ........... ........... ........... ...........
c.
L2525.............. Th/wght bear nar m-l brim .................. A................. ........... ........... ........... ........... ...........
mo.
L2526.............. Th/wght bear nar m-l brim .................. A................. ........... ........... ........... ........... ...........
cu.
L2530.............. Thigh/wght bear lacer non- .................. A................. ........... ........... ........... ........... ...........
mo.
L2540.............. Thigh/wght bear lacer .................. A................. ........... ........... ........... ........... ...........
molded.
L2550.............. Thigh/wght bear high roll .................. A................. ........... ........... ........... ........... ...........
cu.
L2570.............. Hip clevis type 2 posit .................. A................. ........... ........... ........... ........... ...........
jnt.
L2580.............. Pelvic control pelvic .................. A................. ........... ........... ........... ........... ...........
sling.
L2600.............. Hip clevis/thrust bearing .................. A................. ........... ........... ........... ........... ...........
fr.
L2610.............. Hip clevis/thrust bearing .................. A................. ........... ........... ........... ........... ...........
lo.
L2620.............. Pelvic control hip heavy .................. A................. ........... ........... ........... ........... ...........
dut.
L2622.............. Hip joint adjustable .................. A................. ........... ........... ........... ........... ...........
flexion.
L2624.............. Hip adj flex ext abduct .................. A................. ........... ........... ........... ........... ...........
cont.
L2627.............. Plastic mold recipro hip & .................. A................. ........... ........... ........... ........... ...........
c.
L2628.............. Metal frame recipro hip & .................. A................. ........... ........... ........... ........... ...........
ca.
L2630.............. Pelvic control band & belt .................. A................. ........... ........... ........... ........... ...........
u.
L2640.............. Pelvic control band & belt .................. A................. ........... ........... ........... ........... ...........
b.
L2650.............. Pelv & thor control .................. A................. ........... ........... ........... ........... ...........
gluteal.
L2660.............. Thoracic control thoracic .................. A................. ........... ........... ........... ........... ...........
ba.
L2670.............. Thorac cont paraspinal .................. A................. ........... ........... ........... ........... ...........
uprig.
L2680.............. Thorac cont lat support .................. A................. ........... ........... ........... ........... ...........
upri.
L2750.............. Plating chrome/nickel pr .................. A................. ........... ........... ........... ........... ...........
bar.
L2755.............. Carbon graphite lamination .................. A................. ........... ........... ........... ........... ...........
L2760.............. Extension per extension .................. A................. ........... ........... ........... ........... ...........
per.
L2768.............. Ortho sidebar disconnect.. .................. A................. ........... ........... ........... ........... ...........
L2770.............. Low ext orthosis per bar/ .................. A................. ........... ........... ........... ........... ...........
jnt.
[[Page 67152]]
L2780.............. Non-corrosive finish...... .................. A................. ........... ........... ........... ........... ...........
L2785.............. Drop lock retainer each... .................. A................. ........... ........... ........... ........... ...........
L2795.............. Knee control full kneecap. .................. A................. ........... ........... ........... ........... ...........
L2800.............. Knee cap medial or lateral .................. A................. ........... ........... ........... ........... ...........
p.
L2810.............. Knee control condylar pad. .................. A................. ........... ........... ........... ........... ...........
L2820.............. Soft interface below knee .................. A................. ........... ........... ........... ........... ...........
se.
L2830.............. Soft interface above knee .................. A................. ........... ........... ........... ........... ...........
se.
L2840.............. Tibial length sock fx or .................. A................. ........... ........... ........... ........... ...........
equ.
L2850.............. Femoral lgth sock fx or .................. A................. ........... ........... ........... ........... ...........
equa.
L2860.............. Torsion mechanism knee/ .................. A................. ........... ........... ........... ........... ...........
ankle.
L2999.............. Lower extremity orthosis .................. A................. ........... ........... ........... ........... ...........
NOS.
L3000.............. Ft insert ucb berkeley .................. A................. ........... ........... ........... ........... ...........
shell.
L3001.............. Foot insert remov molded .................. A................. ........... ........... ........... ........... ...........
spe.
L3002.............. Foot insert plastazote or .................. A................. ........... ........... ........... ........... ...........
eq.
L3003.............. Foot insert silicone gel .................. A................. ........... ........... ........... ........... ...........
eac.
L3010.............. Foot longitudinal arch .................. A................. ........... ........... ........... ........... ...........
suppo.
L3020.............. Foot longitud/metatarsal .................. A................. ........... ........... ........... ........... ...........
sup.
L3030.............. Foot arch support remov .................. A................. ........... ........... ........... ........... ...........
prem.
L3031.............. Foot lamin/prepreg .................. A................. ........... ........... ........... ........... ...........
composite.
L3040.............. Ft arch suprt premold .................. A................. ........... ........... ........... ........... ...........
longit.
L3050.............. Foot arch supp premold .................. A................. ........... ........... ........... ........... ...........
metat.
L3060.............. Foot arch supp longitud/ .................. A................. ........... ........... ........... ........... ...........
meta.
L3070.............. Arch suprt att to sho .................. A................. ........... ........... ........... ........... ...........
longit.
L3080.............. Arch supp att to shoe .................. A................. ........... ........... ........... ........... ...........
metata.
L3090.............. Arch supp att to shoe long/ .................. A................. ........... ........... ........... ........... ...........
m.
L3100.............. Hallus-valgus nght dynamic .................. A................. ........... ........... ........... ........... ...........
s.
L3140.............. Abduction rotation bar .................. A................. ........... ........... ........... ........... ...........
shoe.
L3150.............. Abduct rotation bar w/o .................. A................. ........... ........... ........... ........... ...........
shoe.
L3160.............. Shoe styled positioning .................. A................. ........... ........... ........... ........... ...........
dev.
L3170.............. Foot plastic heel .................. A................. ........... ........... ........... ........... ...........
stabilizer.
L3201.............. Oxford w supinat/pronat .................. A................. ........... ........... ........... ........... ...........
inf.
L3202.............. Oxford w/ supinat/pronator .................. A................. ........... ........... ........... ........... ...........
c.
L3203.............. Oxford w/ supinator/ .................. A................. ........... ........... ........... ........... ...........
pronator.
L3204.............. Hightop w/ supp/pronator .................. A................. ........... ........... ........... ........... ...........
inf.
L3206.............. Hightop w/ supp/pronator .................. A................. ........... ........... ........... ........... ...........
chi.
L3207.............. Hightop w/ supp/pronator .................. A................. ........... ........... ........... ........... ...........
jun.
L3208.............. Surgical boot each infant. .................. A................. ........... ........... ........... ........... ...........
L3209.............. Surgical boot each child.. .................. A................. ........... ........... ........... ........... ...........
L3211.............. Surgical boot each junior. .................. A................. ........... ........... ........... ........... ...........
L3212.............. Benesch boot pair infant.. .................. A................. ........... ........... ........... ........... ...........
L3213.............. Benesch boot pair child... .................. A................. ........... ........... ........... ........... ...........
L3214.............. Benesch boot pair junior.. .................. A................. ........... ........... ........... ........... ...........
L3215.............. Orthopedic ftwear ladies .................. E................. ........... ........... ........... ........... ...........
oxf.
L3216.............. Orthoped ladies shoes dpth CH................ E................. ........... ........... ........... ........... ...........
i.
L3217.............. Ladies shoes hightop depth CH................ E................. ........... ........... ........... ........... ...........
i.
L3219.............. Orthopedic mens shoes .................. E................. ........... ........... ........... ........... ...........
oxford.
L3221.............. Orthopedic mens shoes dpth CH................ E................. ........... ........... ........... ........... ...........
i.
L3222.............. Mens shoes hightop depth CH................ E................. ........... ........... ........... ........... ...........
inl.
L3224.............. Woman's shoe oxford brace. .................. A................. ........... ........... ........... ........... ...........
L3225.............. Man's shoe oxford brace... .................. A................. ........... ........... ........... ........... ...........
L3230.............. Custom shoes depth inlay.. .................. A................. ........... ........... ........... ........... ...........
L3250.............. Custom mold shoe remov .................. A................. ........... ........... ........... ........... ...........
prost.
L3251.............. Shoe molded to pt silicone .................. A................. ........... ........... ........... ........... ...........
s.
L3252.............. Shoe molded plastazote .................. A................. ........... ........... ........... ........... ...........
cust.
L3253.............. Shoe molded plastazote .................. A................. ........... ........... ........... ........... ...........
cust.
L3254.............. Orth foot non-stndard size/ .................. A................. ........... ........... ........... ........... ...........
w.
L3255.............. Orth foot non-standard .................. A................. ........... ........... ........... ........... ...........
size/.
L3257.............. Orth foot add charge split .................. A................. ........... ........... ........... ........... ...........
s.
L3260.............. Ambulatory surgical boot .................. E................. ........... ........... ........... ........... ...........
eac.
L3265.............. Plastazote sandal each.... .................. A................. ........... ........... ........... ........... ...........
L3300.............. Sho lift taper to .................. A................. ........... ........... ........... ........... ...........
metatarsal.
L3310.............. Shoe lift elev heel/sole .................. A................. ........... ........... ........... ........... ...........
neo.
L3320.............. Shoe lift elev heel/sole .................. A................. ........... ........... ........... ........... ...........
cor.
L3330.............. Lifts elevation metal .................. A................. ........... ........... ........... ........... ...........
extens.
L3332.............. Shoe lifts tapered to one- .................. A................. ........... ........... ........... ........... ...........
ha.
L3334.............. Shoe lifts elevation heel / .................. A................. ........... ........... ........... ........... ...........
i.
L3340.............. Shoe wedge sach........... .................. A................. ........... ........... ........... ........... ...........
L3350.............. Shoe heel wedge........... .................. A................. ........... ........... ........... ........... ...........
L3360.............. Shoe sole wedge outside .................. A................. ........... ........... ........... ........... ...........
sole.
L3370.............. Shoe sole wedge between .................. A................. ........... ........... ........... ........... ...........
sole.
L3380.............. Shoe clubfoot wedge....... .................. A................. ........... ........... ........... ........... ...........
L3390.............. Shoe outflare wedge....... .................. A................. ........... ........... ........... ........... ...........
L3400.............. Shoe metatarsal bar wedge .................. A................. ........... ........... ........... ........... ...........
ro.
L3410.............. Shoe metatarsal bar .................. A................. ........... ........... ........... ........... ...........
between.
L3420.............. Full sole/heel wedge .................. A................. ........... ........... ........... ........... ...........
btween.
L3430.............. Sho heel count plast .................. A................. ........... ........... ........... ........... ...........
reinfor.
L3440.............. Heel leather reinforced... .................. A................. ........... ........... ........... ........... ...........
L3450.............. Shoe heel sach cushion .................. A................. ........... ........... ........... ........... ...........
type.
L3455.............. Shoe heel new leather .................. A................. ........... ........... ........... ........... ...........
standa.
L3460.............. Shoe heel new rubber .................. A................. ........... ........... ........... ........... ...........
standar.
[[Page 67153]]
L3465.............. Shoe heel thomas with .................. A................. ........... ........... ........... ........... ...........
wedge.
L3470.............. Shoe heel thomas extend to .................. A................. ........... ........... ........... ........... ...........
b.
L3480.............. Shoe heel pad & depress .................. A................. ........... ........... ........... ........... ...........
for.
L3485.............. Shoe heel pad removable .................. A................. ........... ........... ........... ........... ...........
for.
L3500.............. Ortho shoe add leather .................. A................. ........... ........... ........... ........... ...........
insol.
L3510.............. Orthopedic shoe add rub .................. A................. ........... ........... ........... ........... ...........
insl.
L3520.............. O shoe add felt w leath .................. A................. ........... ........... ........... ........... ...........
insl.
L3530.............. Ortho shoe add half sole.. .................. A................. ........... ........... ........... ........... ...........
L3540.............. Ortho shoe add full sole.. .................. A................. ........... ........... ........... ........... ...........
L3550.............. O shoe add standard toe .................. A................. ........... ........... ........... ........... ...........
tap.
L3560.............. O shoe add horseshoe toe .................. A................. ........... ........... ........... ........... ...........
tap.
L3570.............. O shoe add instep .................. A................. ........... ........... ........... ........... ...........
extension.
L3580.............. O shoe add instep velcro .................. A................. ........... ........... ........... ........... ...........
clo.
L3590.............. O shoe convert to sof .................. A................. ........... ........... ........... ........... ...........
counte.
L3595.............. Ortho shoe add march bar.. .................. A................. ........... ........... ........... ........... ...........
L3600.............. Trans shoe calip plate .................. A................. ........... ........... ........... ........... ...........
exist.
L3610.............. Trans shoe caliper plate .................. A................. ........... ........... ........... ........... ...........
new.
L3620.............. Trans shoe solid stirrup .................. A................. ........... ........... ........... ........... ...........
exi.
L3630.............. Trans shoe solid stirrup .................. A................. ........... ........... ........... ........... ...........
new.
L3640.............. Shoe dennis browne splint .................. A................. ........... ........... ........... ........... ...........
bo.
L3649.............. Orthopedic shoe modifica .................. A................. ........... ........... ........... ........... ...........
NOS.
L3650.............. Shlder fig 8 abduct .................. A................. ........... ........... ........... ........... ...........
restrain.
L3651.............. Prefab shoulder orthosis.. .................. A................. ........... ........... ........... ........... ...........
L3652.............. Prefab dbl shoulder .................. A................. ........... ........... ........... ........... ...........
orthosis.
L3660.............. Abduct restrainer .................. A................. ........... ........... ........... ........... ...........
canvas&web.
L3670.............. Acromio/clavicular .................. A................. ........... ........... ........... ........... ...........
canvas&we.
L3671.............. SO cap design w/o jnts CF. .................. A................. ........... ........... ........... ........... ...........
L3672.............. SO airplane w/o jnts CF... .................. A................. ........... ........... ........... ........... ...........
L3673.............. SO airplane w/joint CF.... .................. A................. ........... ........... ........... ........... ...........
L3675.............. Canvas vest SO............ .................. A................. ........... ........... ........... ........... ...........
L3677.............. SO hard plastic stabilizer .................. E................. ........... ........... ........... ........... ...........
L3700.............. Elbow orthoses elas w .................. A................. ........... ........... ........... ........... ...........
stays.
L3701.............. Prefab elbow orthosis..... .................. A................. ........... ........... ........... ........... ...........
L3702.............. EO w/o joints CF.......... .................. A................. ........... ........... ........... ........... ...........
L3710.............. Elbow elastic with metal .................. A................. ........... ........... ........... ........... ...........
joi.
L3720.............. Forearm/arm cuffs free .................. A................. ........... ........... ........... ........... ...........
motio.
L3730.............. Forearm/arm cuffs ext/flex .................. A................. ........... ........... ........... ........... ...........
a.
L3740.............. Cuffs adj lock w/ active .................. A................. ........... ........... ........... ........... ...........
con.
L3760.............. EO withjoint, .................. A................. ........... ........... ........... ........... ...........
Prefabricated.
L3762.............. Rigid EO wo joints........ .................. A................. ........... ........... ........... ........... ...........
L3763.............. EWHO rigid w/o jnts CF.... .................. A................. ........... ........... ........... ........... ...........
L3764.............. EWHO w/joint(s) CF........ .................. A................. ........... ........... ........... ........... ...........
L3765.............. EWHFO rigid w/o jnts CF... .................. A................. ........... ........... ........... ........... ...........
L3766.............. EWHFO w/joint(s) CF....... .................. A................. ........... ........... ........... ........... ...........
L3800.............. Whfo short opponen no CH................ D................. ........... ........... ........... ........... ...........
attach.
L3805.............. Whfo long opponens no CH................ D................. ........... ........... ........... ........... ...........
attach.
L3806.............. WHFO w/joint(s) custom fab .................. A................. ........... ........... ........... ........... ...........
L3807.............. WHFO,no joint, .................. A................. ........... ........... ........... ........... ...........
prefabricated.
L3808.............. WHFO, rigid w/o joints.... .................. A................. ........... ........... ........... ........... ...........
L3810.............. Whfo thumb abduction bar.. CH................ D................. ........... ........... ........... ........... ...........
L3815.............. Whfo second m.p. abduction CH................ D................. ........... ........... ........... ........... ...........
a.
L3820.............. Whfo ip ext asst w/ mp ext CH................ D................. ........... ........... ........... ........... ...........
s.
L3825.............. Whfo m.p. extension stop.. CH................ D................. ........... ........... ........... ........... ...........
L3830.............. Whfo m.p. extension assist CH................ D................. ........... ........... ........... ........... ...........
L3835.............. Whfo m.p. spring extension CH................ D................. ........... ........... ........... ........... ...........
a.
L3840.............. Whfo spring swivel thumb.. CH................ D................. ........... ........... ........... ........... ...........
L3845.............. Whfo thumb ip ext ass w/ CH................ D................. ........... ........... ........... ........... ...........
mp.
L3850.............. Action wrist w/ dorsiflex CH................ D................. ........... ........... ........... ........... ...........
as.
L3855.............. Whfo adj m.p. flexion CH................ D................. ........... ........... ........... ........... ...........
contro.
L3860.............. Whfo adj m.p. flex ctrl & CH................ D................. ........... ........... ........... ........... ...........
i.
L3890.............. Torsion mechanism wrist/ .................. B................. ........... ........... ........... ........... ...........
elbo.
L3900.............. Hinge extension/flex wrist/ .................. A................. ........... ........... ........... ........... ...........
f.
L3901.............. Hinge ext/flex wrist .................. A................. ........... ........... ........... ........... ...........
finger.
L3904.............. Whfo electric custom .................. A................. ........... ........... ........... ........... ...........
fitted.
L3905.............. WHO w/nontorsion jnt(s) CF .................. A................. ........... ........... ........... ........... ...........
L3906.............. WHO w/o joints CF......... .................. A................. ........... ........... ........... ........... ...........
L3907.............. Whfo wrst gauntlt thmb CH................ D................. ........... ........... ........... ........... ...........
spica.
L3908.............. Wrist cock-up non-molded.. .................. A................. ........... ........... ........... ........... ...........
L3909.............. Prefab wrist orthosis..... .................. A................. ........... ........... ........... ........... ...........
L3910.............. Whfo swanson design....... CH................ D................. ........... ........... ........... ........... ...........
L3911.............. Prefab hand finger .................. A................. ........... ........... ........... ........... ...........
orthosis.
L3912.............. Flex glove w/elastic .................. A................. ........... ........... ........... ........... ...........
finger.
L3913.............. HFO w/o joints CF......... .................. A................. ........... ........... ........... ........... ...........
L3915.............. WHO w nontor jnt(s) prefab .................. A................. ........... ........... ........... ........... ...........
L3916.............. Whfo wrist extens w/ CH................ D................. ........... ........... ........... ........... ...........
outrigg.
L3917.............. Prefab metacarpl fx .................. A................. ........... ........... ........... ........... ...........
orthosis.
L3918.............. HFO knuckle bender........ CH................ D................. ........... ........... ........... ........... ...........
L3919.............. HO w/o joints CF.......... .................. A................. ........... ........... ........... ........... ...........
L3920.............. Knuckle bender with CH................ D................. ........... ........... ........... ........... ...........
outrigge.
L3921.............. HFO w/joint(s) CF......... .................. A................. ........... ........... ........... ........... ...........
[[Page 67154]]
L3922.............. Knuckle bend 2 seg to flex CH................ D................. ........... ........... ........... ........... ...........
j.
L3923.............. HFO w/o joints PF......... .................. A................. ........... ........... ........... ........... ...........
L3924.............. Oppenheimer............... CH................ D................. ........... ........... ........... ........... ...........
L3925.............. FO pip/dip with joint/ NI................ A................. ........... ........... ........... ........... ...........
spring.
L3926.............. Thomas suspension......... CH................ D................. ........... ........... ........... ........... ...........
L3927.............. FO pip/dip w/o joint/ NI................ A................. ........... ........... ........... ........... ...........
spring.
L3928.............. Finger extension w/ clock CH................ D................. ........... ........... ........... ........... ...........
sp.
L3929.............. HFO nontorsion joint, NI................ A................. ........... ........... ........... ........... ...........
prefab.
L3930.............. Finger extension with CH................ D................. ........... ........... ........... ........... ...........
wrist.
L3931.............. WHFO nontorsion joint NI................ A................. ........... ........... ........... ........... ...........
prefab.
L3932.............. Safety pin spring wire.... CH................ D................. ........... ........... ........... ........... ...........
L3933.............. FO w/o joints CF.......... .................. A................. ........... ........... ........... ........... ...........
L3934.............. Safety pin modified....... CH................ D................. ........... ........... ........... ........... ...........
L3935.............. FO nontorsion joint CF.... .................. A................. ........... ........... ........... ........... ...........
L3936.............. Palmer.................... CH................ D................. ........... ........... ........... ........... ...........
L3938.............. Dorsal wrist.............. CH................ D................. ........... ........... ........... ........... ...........
L3940.............. Dorsal wrist w/ outrigger CH................ D................. ........... ........... ........... ........... ...........
at.
L3942.............. Reverse knuckle bender.... CH................ D................. ........... ........... ........... ........... ...........
L3944.............. Reverse knuckle bend w/ CH................ D................. ........... ........... ........... ........... ...........
outr.
L3946.............. HFO composite elastic..... CH................ D................. ........... ........... ........... ........... ...........
L3948.............. Finger knuckle bender..... CH................ D................. ........... ........... ........... ........... ...........
L3950.............. Oppenheimer w/ knuckle CH................ D................. ........... ........... ........... ........... ...........
bend.
L3952.............. Oppenheimer w/ rev knuckle CH................ D................. ........... ........... ........... ........... ...........
2.
L3954.............. Spreading hand............ CH................ D................. ........... ........... ........... ........... ...........
L3956.............. Add joint upper ext .................. A................. ........... ........... ........... ........... ...........
orthosis.
L3960.............. Sewho airplan desig abdu .................. A................. ........... ........... ........... ........... ...........
pos.
L3961.............. SEWHO cap design w/o jnts .................. A................. ........... ........... ........... ........... ...........
CF.
L3962.............. Sewho erbs palsey design .................. A................. ........... ........... ........... ........... ...........
abd.
L3964.............. Seo mobile arm sup att to .................. Y................. ........... ........... ........... ........... ...........
wc.
L3965.............. Arm supp att to wc rancho .................. Y................. ........... ........... ........... ........... ...........
ty.
L3966.............. Mobile arm supports .................. Y................. ........... ........... ........... ........... ...........
reclinin.
L3967.............. SEWHO airplane w/o jnts CF .................. A................. ........... ........... ........... ........... ...........
L3968.............. Friction dampening arm .................. Y................. ........... ........... ........... ........... ...........
supp.
L3969.............. Monosuspension arm/hand .................. Y................. ........... ........... ........... ........... ...........
supp.
L3970.............. Elevat proximal arm .................. Y................. ........... ........... ........... ........... ...........
support.
L3971.............. SEWHO cap design w/jnt(s) .................. A................. ........... ........... ........... ........... ...........
CF.
L3972.............. Offset/lat rocker arm w/ .................. Y................. ........... ........... ........... ........... ...........
ela.
L3973.............. SEWHO airplane w/jnt(s) CF .................. A................. ........... ........... ........... ........... ...........
L3974.............. Mobile arm support .................. Y................. ........... ........... ........... ........... ...........
supinator.
L3975.............. SEWHFO cap design w/o jnt .................. A................. ........... ........... ........... ........... ...........
CF.
L3976.............. SEWHFO airplane w/o jnts .................. A................. ........... ........... ........... ........... ...........
CF.
L3977.............. SEWHFO cap desgn w/jnt(s) .................. A................. ........... ........... ........... ........... ...........
CF.
L3978.............. SEWHFO airplane w/jnt(s) .................. A................. ........... ........... ........... ........... ...........
CF.
L3980.............. Upp ext fx orthosis .................. A................. ........... ........... ........... ........... ...........
humeral.
L3982.............. Upper ext fx orthosis rad/ .................. A................. ........... ........... ........... ........... ...........
ul.
L3984.............. Upper ext fx orthosis .................. A................. ........... ........... ........... ........... ...........
wrist.
L3985.............. Forearm hand fx orth w/ wr CH................ D................. ........... ........... ........... ........... ...........
h.
L3986.............. Humeral rad/ulna wrist fx CH................ D................. ........... ........... ........... ........... ...........
or.
L3995.............. Sock fracture or equal .................. A................. ........... ........... ........... ........... ...........
each.
L3999.............. Upper limb orthosis NOS... .................. A................. ........... ........... ........... ........... ...........
L4000.............. Repl girdle milwaukee orth .................. A................. ........... ........... ........... ........... ...........
L4002.............. Replace strap, any .................. A................. ........... ........... ........... ........... ...........
orthosis.
L4010.............. Replace trilateral socket .................. A................. ........... ........... ........... ........... ...........
br.
L4020.............. Replace quadlat socket .................. A................. ........... ........... ........... ........... ...........
brim.
L4030.............. Replace socket brim cust .................. A................. ........... ........... ........... ........... ...........
fit.
L4040.............. Replace molded thigh lacer .................. A................. ........... ........... ........... ........... ...........
L4045.............. Replace non-molded thigh .................. A................. ........... ........... ........... ........... ...........
lac.
L4050.............. Replace molded calf lacer. .................. A................. ........... ........... ........... ........... ...........
L4055.............. Replace non-molded calf .................. A................. ........... ........... ........... ........... ...........
lace.
L4060.............. Replace high roll cuff.... .................. A................. ........... ........... ........... ........... ...........
L4070.............. Replace prox & dist .................. A................. ........... ........... ........... ........... ...........
upright.
L4080.............. Repl met band kafo-afo .................. A................. ........... ........... ........... ........... ...........
prox.
L4090.............. Repl met band kafo-afo .................. A................. ........... ........... ........... ........... ...........
calf/.
L4100.............. Repl leath cuff kafo prox .................. A................. ........... ........... ........... ........... ...........
th.
L4110.............. Repl leath cuff kafo-afo .................. A................. ........... ........... ........... ........... ...........
cal.
L4130.............. Replace pretibial shell... .................. A................. ........... ........... ........... ........... ...........
L4205.............. Ortho dvc repair per 15 .................. A................. ........... ........... ........... ........... ...........
min.
L4210.............. Orth dev repair/repl minor .................. A................. ........... ........... ........... ........... ...........
p.
L4350.............. Ankle control orthosi .................. A................. ........... ........... ........... ........... ...........
prefab.
L4360.............. Pneumati walking boot .................. A................. ........... ........... ........... ........... ...........
prefab.
L4370.............. Pneumatic full leg splint. .................. A................. ........... ........... ........... ........... ...........
L4380.............. Pneumatic knee splint..... .................. A................. ........... ........... ........... ........... ...........
L4386.............. Non-pneum walk boot prefab .................. A................. ........... ........... ........... ........... ...........
L4392.............. Replace AFO soft interface .................. A................. ........... ........... ........... ........... ...........
L4394.............. Replace foot drop spint... .................. A................. ........... ........... ........... ........... ...........
L4396.............. Static AFO................ .................. A................. ........... ........... ........... ........... ...........
L4398.............. Foot drop splint recumbent .................. A................. ........... ........... ........... ........... ...........
L5000.............. Sho insert w arch toe .................. A................. ........... ........... ........... ........... ...........
filler.
L5010.............. Mold socket ank hgt w/ toe .................. A................. ........... ........... ........... ........... ...........
f.
L5020.............. Tibial tubercle hgt w/ toe .................. A................. ........... ........... ........... ........... ...........
f.
[[Page 67155]]
L5050.............. Ank symes mold sckt sach .................. A................. ........... ........... ........... ........... ...........
ft.
L5060.............. Symes met fr leath socket .................. A................. ........... ........... ........... ........... ...........
ar.
L5100.............. Molded socket shin sach .................. A................. ........... ........... ........... ........... ...........
foot.
L5105.............. Plast socket jts/thgh .................. A................. ........... ........... ........... ........... ...........
lacer.
L5150.............. Mold sckt ext knee shin .................. A................. ........... ........... ........... ........... ...........
sach.
L5160.............. Mold socket bent knee shin .................. A................. ........... ........... ........... ........... ...........
s.
L5200.............. Kne sing axis fric shin .................. A................. ........... ........... ........... ........... ...........
sach.
L5210.............. No knee/ankle joints w/ ft .................. A................. ........... ........... ........... ........... ...........
b.
L5220.............. No knee joint with artic .................. A................. ........... ........... ........... ........... ...........
ali.
L5230.............. Fem focal defic constant .................. A................. ........... ........... ........... ........... ...........
fri.
L5250.............. Hip canad sing axi cons .................. A................. ........... ........... ........... ........... ...........
fric.
L5270.............. Tilt table locking hip .................. A................. ........... ........... ........... ........... ...........
sing.
L5280.............. Hemipelvect canad sing .................. A................. ........... ........... ........... ........... ...........
axis.
L5301.............. BK mold socket SACH ft .................. A................. ........... ........... ........... ........... ...........
endo.
L5311.............. Knee disart, SACH ft, endo .................. A................. ........... ........... ........... ........... ...........
L5321.............. AK open end SACH.......... .................. A................. ........... ........... ........... ........... ...........
L5331.............. Hip disart canadian SACH .................. A................. ........... ........... ........... ........... ...........
ft.
L5341.............. Hemipelvectomy canadian .................. A................. ........... ........... ........... ........... ...........
SACH.
L5400.............. Postop dress & 1 cast chg .................. A................. ........... ........... ........... ........... ...........
bk.
L5410.............. Postop dsg bk ea add cast .................. A................. ........... ........... ........... ........... ...........
ch.
L5420.............. Postop dsg & 1 cast chg ak/ .................. A................. ........... ........... ........... ........... ...........
d.
L5430.............. Postop dsg ak ea add cast .................. A................. ........... ........... ........... ........... ...........
ch.
L5450.............. Postop app non-wgt bear .................. A................. ........... ........... ........... ........... ...........
dsg.
L5460.............. Postop app non-wgt bear .................. A................. ........... ........... ........... ........... ...........
dsg.
L5500.............. Init bk ptb plaster direct .................. A................. ........... ........... ........... ........... ...........
L5505.............. Init ak ischal plstr .................. A................. ........... ........... ........... ........... ...........
direct.
L5510.............. Prep BK ptb plaster molded .................. A................. ........... ........... ........... ........... ...........
L5520.............. Perp BK ptb thermopls .................. A................. ........... ........... ........... ........... ...........
direct.
L5530.............. Prep BK ptb thermopls .................. A................. ........... ........... ........... ........... ...........
molded.
L5535.............. Prep BK ptb open end .................. A................. ........... ........... ........... ........... ...........
socket.
L5540.............. Prep BK ptb laminated .................. A................. ........... ........... ........... ........... ...........
socket.
L5560.............. Prep AK ischial plast .................. A................. ........... ........... ........... ........... ...........
molded.
L5570.............. Prep AK ischial direct .................. A................. ........... ........... ........... ........... ...........
form.
L5580.............. Prep AK ischial thermo .................. A................. ........... ........... ........... ........... ...........
mold.
L5585.............. Prep AK ischial open end.. .................. A................. ........... ........... ........... ........... ...........
L5590.............. Prep AK ischial laminated. .................. A................. ........... ........... ........... ........... ...........
L5595.............. Hip disartic sach .................. A................. ........... ........... ........... ........... ...........
thermopls.
L5600.............. Hip disart sach laminat .................. A................. ........... ........... ........... ........... ...........
mold.
L5610.............. Above knee hydracadence... .................. A................. ........... ........... ........... ........... ...........
L5611.............. Ak 4 bar link w/fric swing .................. A................. ........... ........... ........... ........... ...........
L5613.............. Ak 4 bar ling w/hydraul .................. A................. ........... ........... ........... ........... ...........
swig.
L5614.............. 4-bar link above knee w/ .................. A................. ........... ........... ........... ........... ...........
swng.
L5616.............. Ak univ multiplex sys .................. A................. ........... ........... ........... ........... ...........
frict.
L5617.............. AK/BK self-aligning unit .................. A................. ........... ........... ........... ........... ...........
ea.
L5618.............. Test socket symes......... .................. A................. ........... ........... ........... ........... ...........
L5620.............. Test socket below knee.... .................. A................. ........... ........... ........... ........... ...........
L5622.............. Test socket knee .................. A................. ........... ........... ........... ........... ...........
disarticula.
L5624.............. Test socket above knee.... .................. A................. ........... ........... ........... ........... ...........
L5626.............. Test socket hip .................. A................. ........... ........... ........... ........... ...........
disarticulat.
L5628.............. Test socket hemipelvectomy .................. A................. ........... ........... ........... ........... ...........
L5629.............. Below knee acrylic socket. .................. A................. ........... ........... ........... ........... ...........
L5630.............. Syme typ expandabl wall .................. A................. ........... ........... ........... ........... ...........
sckt.
L5631.............. Ak/knee disartic acrylic .................. A................. ........... ........... ........... ........... ...........
soc.
L5632.............. Symes type ptb brim design .................. A................. ........... ........... ........... ........... ...........
s.
L5634.............. Symes type poster opening .................. A................. ........... ........... ........... ........... ...........
so.
L5636.............. Symes type medial opening .................. A................. ........... ........... ........... ........... ...........
so.
L5637.............. Below knee total contact.. .................. A................. ........... ........... ........... ........... ...........
L5638.............. Below knee leather socket. .................. A................. ........... ........... ........... ........... ...........
L5639.............. Below knee wood socket.... .................. A................. ........... ........... ........... ........... ...........
L5640.............. Knee disarticulat leather .................. A................. ........... ........... ........... ........... ...........
so.
L5642.............. Above knee leather socket. .................. A................. ........... ........... ........... ........... ...........
L5643.............. Hip flex inner socket ext .................. A................. ........... ........... ........... ........... ...........
fr.
L5644.............. Above knee wood socket.... .................. A................. ........... ........... ........... ........... ...........
L5645.............. Bk flex inner socket ext .................. A................. ........... ........... ........... ........... ...........
fra.
L5646.............. Below knee cushion socket. .................. A................. ........... ........... ........... ........... ...........
L5647.............. Below knee suction socket. .................. A................. ........... ........... ........... ........... ...........
L5648.............. Above knee cushion socket. .................. A................. ........... ........... ........... ........... ...........
L5649.............. Isch containmt/narrow m-l .................. A................. ........... ........... ........... ........... ...........
so.
L5650.............. Tot contact ak/knee disart .................. A................. ........... ........... ........... ........... ...........
s.
L5651.............. Ak flex inner socket ext .................. A................. ........... ........... ........... ........... ...........
fra.
L5652.............. Suction susp ak/knee .................. A................. ........... ........... ........... ........... ...........
disart.
L5653.............. Knee disart expand wall .................. A................. ........... ........... ........... ........... ...........
sock.
L5654.............. Socket insert symes....... .................. A................. ........... ........... ........... ........... ...........
L5655.............. Socket insert below knee.. .................. A................. ........... ........... ........... ........... ...........
L5656.............. Socket insert knee .................. A................. ........... ........... ........... ........... ...........
articulat.
L5658.............. Socket insert above knee.. .................. A................. ........... ........... ........... ........... ...........
L5661.............. Multi-durometer symes..... .................. A................. ........... ........... ........... ........... ...........
L5665.............. Multi-durometer below knee .................. A................. ........... ........... ........... ........... ...........
L5666.............. Below knee cuff suspension .................. A................. ........... ........... ........... ........... ...........
L5668.............. Socket insert w/o lock .................. A................. ........... ........... ........... ........... ...........
lower.
[[Page 67156]]
L5670.............. Bk molded supracondylar .................. A................. ........... ........... ........... ........... ...........
susp.
L5671.............. BK/AK locking mechanism... .................. A................. ........... ........... ........... ........... ...........
L5672.............. Bk removable medial brim .................. A................. ........... ........... ........... ........... ...........
sus.
L5673.............. Socket insert w lock mech. .................. A................. ........... ........... ........... ........... ...........
L5676.............. Bk knee joints single axis .................. A................. ........... ........... ........... ........... ...........
p.
L5677.............. Bk knee joints polycentric .................. A................. ........... ........... ........... ........... ...........
p.
L5678.............. Bk joint covers pair...... .................. A................. ........... ........... ........... ........... ...........
L5679.............. Socket insert w/o lock .................. A................. ........... ........... ........... ........... ...........
mech.
L5680.............. Bk thigh lacer non-molded. .................. A................. ........... ........... ........... ........... ...........
L5681.............. Intl custm cong/latyp .................. A................. ........... ........... ........... ........... ...........
insert.
L5682.............. Bk thigh lacer glut/ischia .................. A................. ........... ........... ........... ........... ...........
m.
L5683.............. Initial custom socket .................. A................. ........... ........... ........... ........... ...........
insert.
L5684.............. Bk fork strap............. .................. A................. ........... ........... ........... ........... ...........
L5685.............. Below knee sus/seal sleeve .................. A................. ........... ........... ........... ........... ...........
L5686.............. Bk back check............. .................. A................. ........... ........... ........... ........... ...........
L5688.............. Bk waist belt webbing..... .................. A................. ........... ........... ........... ........... ...........
L5690.............. Bk waist belt padded and .................. A................. ........... ........... ........... ........... ...........
lin.
L5692.............. Ak pelvic control belt .................. A................. ........... ........... ........... ........... ...........
light.
L5694.............. Ak pelvic control belt pad/ .................. A................. ........... ........... ........... ........... ...........
l.
L5695.............. Ak sleeve susp neoprene/ .................. A................. ........... ........... ........... ........... ...........
equa.
L5696.............. Ak/knee disartic pelvic .................. A................. ........... ........... ........... ........... ...........
join.
L5697.............. Ak/knee disartic pelvic .................. A................. ........... ........... ........... ........... ...........
band.
L5698.............. Ak/knee disartic silesian .................. A................. ........... ........... ........... ........... ...........
ba.
L5699.............. Shoulder harness.......... .................. A................. ........... ........... ........... ........... ...........
L5700.............. Replace socket below knee. .................. A................. ........... ........... ........... ........... ...........
L5701.............. Replace socket above knee. .................. A................. ........... ........... ........... ........... ...........
L5702.............. Replace socket hip........ .................. A................. ........... ........... ........... ........... ...........
L5703.............. Symes ankle w/o (SACH) .................. A................. ........... ........... ........... ........... ...........
foot.
L5704.............. Custom shape cover BK..... .................. A................. ........... ........... ........... ........... ...........
L5705.............. Custom shape cover AK..... .................. A................. ........... ........... ........... ........... ...........
L5706.............. Custom shape cvr knee .................. A................. ........... ........... ........... ........... ...........
disart.
L5707.............. Custom shape cvr hip .................. A................. ........... ........... ........... ........... ...........
disart.
L5710.............. Kne-shin exo sng axi mnl .................. A................. ........... ........... ........... ........... ...........
loc.
L5711.............. Knee-shin exo mnl lock .................. A................. ........... ........... ........... ........... ...........
ultra.
L5712.............. Knee-shin exo frict swg & .................. A................. ........... ........... ........... ........... ...........
st.
L5714.............. Knee-shin exo variable .................. A................. ........... ........... ........... ........... ...........
frict.
L5716.............. Knee-shin exo mech stance .................. A................. ........... ........... ........... ........... ...........
ph.
L5718.............. Knee-shin exo frct swg & .................. A................. ........... ........... ........... ........... ...........
sta.
L5722.............. Knee-shin pneum swg frct .................. A................. ........... ........... ........... ........... ...........
exo.
L5724.............. Knee-shin exo fluid swing .................. A................. ........... ........... ........... ........... ...........
ph.
L5726.............. Knee-shin ext jnts fld swg .................. A................. ........... ........... ........... ........... ...........
e.
L5728.............. Knee-shin fluid swg & .................. A................. ........... ........... ........... ........... ...........
stance.
L5780.............. Knee-shin pneum/hydra .................. A................. ........... ........... ........... ........... ...........
pneum.
L5781.............. Lower limb pros vacuum .................. A................. ........... ........... ........... ........... ...........
pump.
L5782.............. HD low limb pros vacuum .................. A................. ........... ........... ........... ........... ...........
pump.
L5785.............. Exoskeletal bk ultralt .................. A................. ........... ........... ........... ........... ...........
mater.
L5790.............. Exoskeletal ak ultra-light .................. A................. ........... ........... ........... ........... ...........
m.
L5795.............. Exoskel hip ultra-light .................. A................. ........... ........... ........... ........... ...........
mate.
L5810.............. Endoskel knee-shin mnl .................. A................. ........... ........... ........... ........... ...........
lock.
L5811.............. Endo knee-shin mnl lck .................. A................. ........... ........... ........... ........... ...........
ultra.
L5812.............. Endo knee-shin frct swg & .................. A................. ........... ........... ........... ........... ...........
st.
L5814.............. Endo knee-shin hydral swg .................. A................. ........... ........... ........... ........... ...........
ph.
L5816.............. Endo knee-shin polyc mch .................. A................. ........... ........... ........... ........... ...........
sta.
L5818.............. Endo knee-shin frct swg & .................. A................. ........... ........... ........... ........... ...........
st.
L5822.............. Endo knee-shin pneum swg .................. A................. ........... ........... ........... ........... ...........
frc.
L5824.............. Endo knee-shin fluid swing .................. A................. ........... ........... ........... ........... ...........
p.
L5826.............. Miniature knee joint...... .................. A................. ........... ........... ........... ........... ...........
L5828.............. Endo knee-shin fluid swg/ .................. A................. ........... ........... ........... ........... ...........
sta.
L5830.............. Endo knee-shin pneum/swg .................. A................. ........... ........... ........... ........... ...........
pha.
L5840.............. Multi-axial knee/shin .................. A................. ........... ........... ........... ........... ...........
system.
L5845.............. Knee-shin sys stance .................. A................. ........... ........... ........... ........... ...........
flexion.
L5848.............. Knee-shin sys hydraul .................. A................. ........... ........... ........... ........... ...........
stance.
L5850.............. Endo ak/hip knee extens .................. A................. ........... ........... ........... ........... ...........
assi.
L5855.............. Mech hip extension assist. .................. A................. ........... ........... ........... ........... ...........
L5856.............. Elec knee-shin swing/ .................. A................. ........... ........... ........... ........... ...........
stance.
L5857.............. Elec knee-shin swing only. .................. A................. ........... ........... ........... ........... ...........
L5858.............. Stance phase only......... .................. A................. ........... ........... ........... ........... ...........
L5910.............. Endo below knee alignable .................. A................. ........... ........... ........... ........... ...........
sy.
L5920.............. Endo ak/hip alignable .................. A................. ........... ........... ........... ........... ...........
system.
L5925.............. Above knee manual lock.... .................. A................. ........... ........... ........... ........... ...........
L5930.............. High activity knee frame.. .................. A................. ........... ........... ........... ........... ...........
L5940.............. Endo bk ultra-light .................. A................. ........... ........... ........... ........... ...........
material.
L5950.............. Endo ak ultra-light .................. A................. ........... ........... ........... ........... ...........
material.
L5960.............. Endo hip ultra-light .................. A................. ........... ........... ........... ........... ...........
materia.
L5962.............. Below knee flex cover .................. A................. ........... ........... ........... ........... ...........
system.
L5964.............. Above knee flex cover .................. A................. ........... ........... ........... ........... ...........
system.
L5966.............. Hip flexible cover system. .................. A................. ........... ........... ........... ........... ...........
L5968.............. Multiaxial ankle w .................. A................. ........... ........... ........... ........... ...........
dorsiflex.
L5970.............. Foot external keel sach .................. A................. ........... ........... ........... ........... ...........
foot.
L5971.............. SACH foot, replacement.... .................. A................. ........... ........... ........... ........... ...........
[[Page 67157]]
L5972.............. Flexible keel foot........ .................. A................. ........... ........... ........... ........... ...........
L5974.............. Foot single axis ankle/ .................. A................. ........... ........... ........... ........... ...........
foot.
L5975.............. Combo ankle/foot .................. A................. ........... ........... ........... ........... ...........
prosthesis.
L5976.............. Energy storing foot....... .................. A................. ........... ........... ........... ........... ...........
L5978.............. Ft prosth multiaxial ankl/ .................. A................. ........... ........... ........... ........... ...........
ft.
L5979.............. Multi-axial ankle/ft .................. A................. ........... ........... ........... ........... ...........
prosth.
L5980.............. Flex foot system.......... .................. A................. ........... ........... ........... ........... ...........
L5981.............. Flex-walk sys low ext .................. A................. ........... ........... ........... ........... ...........
prosth.
L5982.............. Exoskeletal axial rotation .................. A................. ........... ........... ........... ........... ...........
u.
L5984.............. Endoskeletal axial .................. A................. ........... ........... ........... ........... ...........
rotation.
L5985.............. Lwr ext dynamic prosth .................. A................. ........... ........... ........... ........... ...........
pylon.
L5986.............. Multi-axial rotation unit. .................. A................. ........... ........... ........... ........... ...........
L5987.............. Shank ft w vert load pylon .................. A................. ........... ........... ........... ........... ...........
L5988.............. Vertical shock reducing .................. A................. ........... ........... ........... ........... ...........
pylo.
L5990.............. User adjustable heel .................. A................. ........... ........... ........... ........... ...........
height.
L5993.............. Heavy duty feature, foot.. .................. A................. ........... ........... ........... ........... ...........
L5994.............. Heavy duty feature, knee.. .................. A................. ........... ........... ........... ........... ...........
L5995.............. Lower ext pros heavyduty .................. A................. ........... ........... ........... ........... ...........
fea.
L5999.............. Lowr extremity prosthes .................. A................. ........... ........... ........... ........... ...........
NOS.
L6000.............. Par hand robin-aids thum .................. A................. ........... ........... ........... ........... ...........
rem.
L6010.............. Hand robin-aids little/ .................. A................. ........... ........... ........... ........... ...........
ring.
L6020.............. Part hand robin-aids no .................. A................. ........... ........... ........... ........... ...........
fing.
L6025.............. Part hand disart .................. A................. ........... ........... ........... ........... ...........
myoelectric.
L6050.............. Wrst MLd sck flx hng tri .................. A................. ........... ........... ........... ........... ...........
pad.
L6055.............. Wrst mold sock w/exp .................. A................. ........... ........... ........... ........... ...........
interfa.
L6100.............. Elb mold sock flex hinge .................. A................. ........... ........... ........... ........... ...........
pad.
L6110.............. Elbow mold sock suspension .................. A................. ........... ........... ........... ........... ...........
t.
L6120.............. Elbow mold doub splt soc .................. A................. ........... ........... ........... ........... ...........
ste.
L6130.............. Elbow stump activated lock .................. A................. ........... ........... ........... ........... ...........
h.
L6200.............. Elbow mold outsid lock .................. A................. ........... ........... ........... ........... ...........
hinge.
L6205.............. Elbow molded w/ expand .................. A................. ........... ........... ........... ........... ...........
inter.
L6250.............. Elbow inter loc elbow .................. A................. ........... ........... ........... ........... ...........
forarm.
L6300.............. Shlder disart int lock .................. A................. ........... ........... ........... ........... ...........
elbow.
L6310.............. Shoulder passive restor .................. A................. ........... ........... ........... ........... ...........
comp.
L6320.............. Shoulder passive restor .................. A................. ........... ........... ........... ........... ...........
cap.
L6350.............. Thoracic intern lock elbow .................. A................. ........... ........... ........... ........... ...........
L6360.............. Thoracic passive restor .................. A................. ........... ........... ........... ........... ...........
comp.
L6370.............. Thoracic passive restor .................. A................. ........... ........... ........... ........... ...........
cap.
L6380.............. Postop dsg cast chg wrst/ .................. A................. ........... ........... ........... ........... ...........
elb.
L6382.............. Postop dsg cast chg elb .................. A................. ........... ........... ........... ........... ...........
dis/.
L6384.............. Postop dsg cast chg shlder/ .................. A................. ........... ........... ........... ........... ...........
t.
L6386.............. Postop ea cast chg & .................. A................. ........... ........... ........... ........... ...........
realign.
L6388.............. Postop applicat rigid dsg .................. A................. ........... ........... ........... ........... ...........
on.
L6400.............. Below elbow prosth tiss .................. A................. ........... ........... ........... ........... ...........
shap.
L6450.............. Elb disart prosth tiss .................. A................. ........... ........... ........... ........... ...........
shap.
L6500.............. Above elbow prosth tiss .................. A................. ........... ........... ........... ........... ...........
shap.
L6550.............. Shldr disar prosth tiss .................. A................. ........... ........... ........... ........... ...........
shap.
L6570.............. Scap thorac prosth tiss .................. A................. ........... ........... ........... ........... ...........
shap.
L6580.............. Wrist/elbow bowden cable .................. A................. ........... ........... ........... ........... ...........
mol.
L6582.............. Wrist/elbow bowden cbl dir .................. A................. ........... ........... ........... ........... ...........
f.
L6584.............. Elbow fair lead cable .................. A................. ........... ........... ........... ........... ...........
molded.
L6586.............. Elbow fair lead cable dir .................. A................. ........... ........... ........... ........... ...........
fo.
L6588.............. Shdr fair lead cable .................. A................. ........... ........... ........... ........... ...........
molded.
L6590.............. Shdr fair lead cable .................. A................. ........... ........... ........... ........... ...........
direct.
L6600.............. Polycentric hinge pair.... .................. A................. ........... ........... ........... ........... ...........
L6605.............. Single pivot hinge pair... .................. A................. ........... ........... ........... ........... ...........
L6610.............. Flexible metal hinge pair. .................. A................. ........... ........... ........... ........... ...........
L6611.............. Additional switch, ext .................. A................. ........... ........... ........... ........... ...........
power.
L6615.............. Disconnect locking wrist .................. A................. ........... ........... ........... ........... ...........
uni.
L6616.............. Disconnect insert locking .................. A................. ........... ........... ........... ........... ...........
wr.
L6620.............. Flexion/extension wrist .................. A................. ........... ........... ........... ........... ...........
unit.
L6621.............. Flex/ext wrist w/wo .................. A................. ........... ........... ........... ........... ...........
friction.
L6623.............. Spring-ass rot wrst w/ .................. A................. ........... ........... ........... ........... ...........
latch.
L6624.............. Flex/ext/rotation wrist .................. A................. ........... ........... ........... ........... ...........
unit.
L6625.............. Rotation wrst w/ cable .................. A................. ........... ........... ........... ........... ...........
lock.
L6628.............. Quick disconn hook adapter .................. A................. ........... ........... ........... ........... ...........
o.
L6629.............. Lamination collar w/ .................. A................. ........... ........... ........... ........... ...........
couplin.
L6630.............. Stainless steel any wrist. .................. A................. ........... ........... ........... ........... ...........
L6632.............. Latex suspension sleeve .................. A................. ........... ........... ........... ........... ...........
each.
L6635.............. Lift assist for elbow..... .................. A................. ........... ........... ........... ........... ...........
L6637.............. Nudge control elbow lock.. .................. A................. ........... ........... ........... ........... ...........
L6638.............. Elec lock on manual pw .................. A................. ........... ........... ........... ........... ...........
elbow.
L6639.............. Heavy duty elbow feature.. .................. A................. ........... ........... ........... ........... ...........
L6640.............. Shoulder abduction joint .................. A................. ........... ........... ........... ........... ...........
pai.
L6641.............. Excursion amplifier pulley .................. A................. ........... ........... ........... ........... ...........
t.
L6642.............. Excursion amplifier lever .................. A................. ........... ........... ........... ........... ...........
ty.
L6645.............. Shoulder flexion-abduction .................. A................. ........... ........... ........... ........... ...........
j.
L6646.............. Multipo locking shoulder .................. A................. ........... ........... ........... ........... ...........
jnt.
L6647.............. Shoulder lock actuator.... .................. A................. ........... ........... ........... ........... ...........
L6648.............. Ext pwrd shlder lock/ .................. A................. ........... ........... ........... ........... ...........
unlock.
[[Page 67158]]
L6650.............. Shoulder universal joint.. .................. A................. ........... ........... ........... ........... ...........
L6655.............. Standard control cable .................. A................. ........... ........... ........... ........... ...........
extra.
L6660.............. Heavy duty control cable.. .................. A................. ........... ........... ........... ........... ...........
L6665.............. Teflon or equal cable .................. A................. ........... ........... ........... ........... ...........
lining.
L6670.............. Hook to hand cable adapter .................. A................. ........... ........... ........... ........... ...........
L6672.............. Harness chest/shlder .................. A................. ........... ........... ........... ........... ...........
saddle.
L6675.............. Harness figure of 8 sing .................. A................. ........... ........... ........... ........... ...........
con.
L6676.............. Harness figure of 8 dual .................. A................. ........... ........... ........... ........... ...........
con.
L6677.............. UE triple control harness. .................. A................. ........... ........... ........... ........... ...........
L6680.............. Test sock wrist disart/bel .................. A................. ........... ........... ........... ........... ...........
e.
L6682.............. Test sock elbw disart/ .................. A................. ........... ........... ........... ........... ...........
above.
L6684.............. Test socket shldr disart/ .................. A................. ........... ........... ........... ........... ...........
tho.
L6686.............. Suction socket............ .................. A................. ........... ........... ........... ........... ...........
L6687.............. Frame typ socket bel elbow/ .................. A................. ........... ........... ........... ........... ...........
w.
L6688.............. Frame typ sock above elb/ .................. A................. ........... ........... ........... ........... ...........
dis.
L6689.............. Frame typ socket shoulder .................. A................. ........... ........... ........... ........... ...........
di.
L6690.............. Frame typ sock interscap- .................. A................. ........... ........... ........... ........... ...........
tho.
L6691.............. Removable insert each..... .................. A................. ........... ........... ........... ........... ...........
L6692.............. Silicone gel insert or .................. A................. ........... ........... ........... ........... ...........
equal.
L6693.............. Lockingelbow forearm .................. A................. ........... ........... ........... ........... ...........
cntrbal.
L6694.............. Elbow socket ins use w/ .................. A................. ........... ........... ........... ........... ...........
lock.
L6695.............. Elbow socket ins use w/o .................. A................. ........... ........... ........... ........... ...........
lck.
L6696.............. Cus elbo skt in for con/ .................. A................. ........... ........... ........... ........... ...........
atyp.
L6697.............. Cus elbo skt in not con/ .................. A................. ........... ........... ........... ........... ...........
atyp.
L6698.............. Below/above elbow lock .................. A................. ........... ........... ........... ........... ...........
mech.
L6703.............. Term dev, passive hand .................. A................. ........... ........... ........... ........... ...........
mitt.
L6704.............. Term dev, sport/rec/work .................. A................. ........... ........... ........... ........... ...........
att.
L6706.............. Term dev mech hook vol .................. A................. ........... ........... ........... ........... ...........
open.
L6707.............. Term dev mech hook vol .................. A................. ........... ........... ........... ........... ...........
close.
L6708.............. Term dev mech hand vol .................. A................. ........... ........... ........... ........... ...........
open.
L6709.............. Term dev mech hand vol .................. A................. ........... ........... ........... ........... ...........
close.
L6805.............. Term dev modifier wrist .................. A................. ........... ........... ........... ........... ...........
unit.
L6810.............. Term dev precision pinch .................. A................. ........... ........... ........... ........... ...........
dev.
L6881.............. Term dev auto grasp .................. A................. ........... ........... ........... ........... ...........
feature.
L6882.............. Microprocessor control .................. A................. ........... ........... ........... ........... ...........
uplmb.
L6883.............. Replc sockt below e/w disa .................. A................. ........... ........... ........... ........... ...........
L6884.............. Replc sockt above elbow .................. A................. ........... ........... ........... ........... ...........
disa.
L6885.............. Replc sockt shldr dis/ .................. A................. ........... ........... ........... ........... ...........
interc.
L6890.............. Prefab glove for term .................. A................. ........... ........... ........... ........... ...........
device.
L6895.............. Custom glove for term .................. A................. ........... ........... ........... ........... ...........
device.
L6900.............. Hand restorat thumb/1 .................. A................. ........... ........... ........... ........... ...........
finger.
L6905.............. Hand restoration multiple .................. A................. ........... ........... ........... ........... ...........
fi.
L6910.............. Hand restoration no .................. A................. ........... ........... ........... ........... ...........
fingers.
L6915.............. Hand restoration replacmnt .................. A................. ........... ........... ........... ........... ...........
g.
L6920.............. Wrist disarticul switch .................. A................. ........... ........... ........... ........... ...........
ctrl.
L6925.............. Wrist disart myoelectronic .................. A................. ........... ........... ........... ........... ...........
c.
L6930.............. Below elbow switch control .................. A................. ........... ........... ........... ........... ...........
L6935.............. Below elbow myoelectronic .................. A................. ........... ........... ........... ........... ...........
ct.
L6940.............. Elbow disarticulation .................. A................. ........... ........... ........... ........... ...........
switch.
L6945.............. Elbow disart myoelectronic .................. A................. ........... ........... ........... ........... ...........
c.
L6950.............. Above elbow switch control .................. A................. ........... ........... ........... ........... ...........
L6955.............. Above elbow myoelectronic .................. A................. ........... ........... ........... ........... ...........
ct.
L6960.............. Shldr disartic switch .................. A................. ........... ........... ........... ........... ...........
contro.
L6965.............. Shldr disartic .................. A................. ........... ........... ........... ........... ...........
myoelectronic.
L6970.............. Interscapular-thor switch .................. A................. ........... ........... ........... ........... ...........
ct.
L6975.............. Interscap-thor .................. A................. ........... ........... ........... ........... ...........
myoelectronic.
L7007.............. Adult electric hand....... .................. A................. ........... ........... ........... ........... ...........
L7008.............. Pediatric electric hand... .................. A................. ........... ........... ........... ........... ...........
L7009.............. Adult electric hook....... .................. A................. ........... ........... ........... ........... ...........
L7040.............. Prehensile actuator....... .................. A................. ........... ........... ........... ........... ...........
L7045.............. Pediatric electric hook... .................. A................. ........... ........... ........... ........... ...........
L7170.............. Electronic elbow hosmer .................. A................. ........... ........... ........... ........... ...........
swit.
L7180.............. Electronic elbow .................. A................. ........... ........... ........... ........... ...........
sequential.
L7181.............. Electronic elbo .................. A................. ........... ........... ........... ........... ...........
simultaneous.
L7185.............. Electron elbow adolescent .................. A................. ........... ........... ........... ........... ...........
sw.
L7186.............. Electron elbow child .................. A................. ........... ........... ........... ........... ...........
switch.
L7190.............. Elbow adolescent .................. A................. ........... ........... ........... ........... ...........
myoelectron.
L7191.............. Elbow child myoelectronic .................. A................. ........... ........... ........... ........... ...........
ct.
L7260.............. Electron wrist rotator .................. A................. ........... ........... ........... ........... ...........
otto.
L7261.............. Electron wrist rotator .................. A................. ........... ........... ........... ........... ...........
utah.
L7266.............. Servo control steeper or .................. A................. ........... ........... ........... ........... ...........
equ.
L7272.............. Analogue control unb or .................. A................. ........... ........... ........... ........... ...........
equa.
L7274.............. Proportional ctl 12 volt .................. A................. ........... ........... ........... ........... ...........
uta.
L7360.............. Six volt bat otto bock/eq .................. A................. ........... ........... ........... ........... ...........
ea.
L7362.............. Battery chrgr six volt .................. A................. ........... ........... ........... ........... ...........
otto.
L7364.............. Twelve volt battery utah/ .................. A................. ........... ........... ........... ........... ...........
equ.
L7366.............. Battery chrgr 12 volt utah/ .................. A................. ........... ........... ........... ........... ...........
e.
L7367.............. Replacemnt lithium .................. A................. ........... ........... ........... ........... ...........
ionbatter.
L7368.............. Lithium ion battery .................. A................. ........... ........... ........... ........... ...........
charger.
L7400.............. Add UE prost be/wd, .................. A................. ........... ........... ........... ........... ...........
ultlite.
[[Page 67159]]
L7401.............. Add UE prost a/e ultlite .................. A................. ........... ........... ........... ........... ...........
mat.
L7402.............. Add UE prost s/d ultlite .................. A................. ........... ........... ........... ........... ...........
mat.
L7403.............. Add UE prost b/e acrylic.. .................. A................. ........... ........... ........... ........... ...........
L7404.............. Add UE prost a/e acrylic.. .................. A................. ........... ........... ........... ........... ...........
L7405.............. Add UE prost s/d acrylic.. .................. A................. ........... ........... ........... ........... ...........
L7499.............. Upper extremity prosthes .................. A................. ........... ........... ........... ........... ...........
NOS.
L7500.............. Prosthetic dvc repair .................. A................. ........... ........... ........... ........... ...........
hourly.
L7510.............. Prosthetic device repair .................. A................. ........... ........... ........... ........... ...........
rep.
L7520.............. Repair prosthesis per 15 .................. A................. ........... ........... ........... ........... ...........
min.
L7600.............. Prosthetic donning sleeve. .................. E................. ........... ........... ........... ........... ...........
L7611.............. Ped term dev, hook, vol NI................ A................. ........... ........... ........... ........... ...........
open.
L7612.............. Ped term dev, hook, vol NI................ A................. ........... ........... ........... ........... ...........
clos.
L7613.............. Ped term dev, hand, vol NI................ A................. ........... ........... ........... ........... ...........
open.
L7614.............. Ped term dev, hand, vol NI................ A................. ........... ........... ........... ........... ...........
clos.
L7621.............. Hook/hand, hvy dty, vol NI................ A................. ........... ........... ........... ........... ...........
open.
L7622.............. Hook/hand, hvy dty, vol NI................ A................. ........... ........... ........... ........... ...........
clos.
L7900.............. Male vacuum erection .................. A................. ........... ........... ........... ........... ...........
system.
L8000.............. Mastectomy bra............ .................. A................. ........... ........... ........... ........... ...........
L8001.............. Breast prosthesis bra & .................. A................. ........... ........... ........... ........... ...........
form.
L8002.............. Brst prsth bra & bilat .................. A................. ........... ........... ........... ........... ...........
form.
L8010.............. Mastectomy sleeve......... .................. A................. ........... ........... ........... ........... ...........
L8015.............. Ext breastprosthesis .................. A................. ........... ........... ........... ........... ...........
garment.
L8020.............. Mastectomy form........... .................. A................. ........... ........... ........... ........... ...........
L8030.............. Breast prosthesis silicone/ .................. A................. ........... ........... ........... ........... ...........
e.
L8035.............. Custom breast prosthesis.. .................. A................. ........... ........... ........... ........... ...........
L8039.............. Breast prosthesis NOS..... .................. A................. ........... ........... ........... ........... ...........
L8040.............. Nasal prosthesis.......... .................. A................. ........... ........... ........... ........... ...........
L8041.............. Midfacial prosthesis...... .................. A................. ........... ........... ........... ........... ...........
L8042.............. Orbital prosthesis........ .................. A................. ........... ........... ........... ........... ...........
L8043.............. Upper facial prosthesis... .................. A................. ........... ........... ........... ........... ...........
L8044.............. Hemi-facial prosthesis.... .................. A................. ........... ........... ........... ........... ...........
L8045.............. Auricular prosthesis...... .................. A................. ........... ........... ........... ........... ...........
L8046.............. Partial facial prosthesis. .................. A................. ........... ........... ........... ........... ...........
L8047.............. Nasal septal prosthesis... .................. A................. ........... ........... ........... ........... ...........
L8048.............. Unspec maxillofacial .................. A................. ........... ........... ........... ........... ...........
prosth.
L8049.............. Repair maxillofacial .................. A................. ........... ........... ........... ........... ...........
prosth.
L8300.............. Truss single w/ standard .................. A................. ........... ........... ........... ........... ...........
pad.
L8310.............. Truss double w/ standard .................. A................. ........... ........... ........... ........... ...........
pad.
L8320.............. Truss addition to std pad .................. A................. ........... ........... ........... ........... ...........
wa.
L8330.............. Truss add to std pad .................. A................. ........... ........... ........... ........... ...........
scrotal.
L8400.............. Sheath below knee......... .................. A................. ........... ........... ........... ........... ...........
L8410.............. Sheath above knee......... .................. A................. ........... ........... ........... ........... ...........
L8415.............. Sheath upper limb......... .................. A................. ........... ........... ........... ........... ...........
L8417.............. Pros sheath/sock w gel .................. A................. ........... ........... ........... ........... ...........
cushn.
L8420.............. Prosthetic sock multi ply .................. A................. ........... ........... ........... ........... ...........
BK.
L8430.............. Prosthetic sock multi ply .................. A................. ........... ........... ........... ........... ...........
AK.
L8435.............. Pros sock multi ply upper .................. A................. ........... ........... ........... ........... ...........
lm.
L8440.............. Shrinker below knee....... .................. A................. ........... ........... ........... ........... ...........
L8460.............. Shrinker above knee....... .................. A................. ........... ........... ........... ........... ...........
L8465.............. Shrinker upper limb....... .................. A................. ........... ........... ........... ........... ...........
L8470.............. Pros sock single ply BK... .................. A................. ........... ........... ........... ........... ...........
L8480.............. Pros sock single ply AK... .................. A................. ........... ........... ........... ........... ...........
L8485.............. Pros sock single ply upper .................. A................. ........... ........... ........... ........... ...........
l.
L8499.............. Unlisted misc prosthetic .................. A................. ........... ........... ........... ........... ...........
ser.
L8500.............. Artificial larynx......... .................. A................. ........... ........... ........... ........... ...........
L8501.............. Tracheostomy speaking .................. A................. ........... ........... ........... ........... ...........
valve.
L8505.............. Artificial larynx, .................. A................. ........... ........... ........... ........... ...........
accessory.
L8507.............. Trach-esoph voice pros pt .................. A................. ........... ........... ........... ........... ...........
in.
L8509.............. Trach-esoph voice pros md .................. A................. ........... ........... ........... ........... ...........
in.
L8510.............. Voice amplifier........... .................. A................. ........... ........... ........... ........... ...........
L8511.............. Indwelling trach insert... .................. A................. ........... ........... ........... ........... ...........
L8512.............. Gel cap for trach voice .................. A................. ........... ........... ........... ........... ...........
pros.
L8513.............. Trach pros cleaning device .................. A................. ........... ........... ........... ........... ...........
L8514.............. Repl trach puncture .................. A................. ........... ........... ........... ........... ...........
dilator.
L8515.............. Gel cap app device for .................. A................. ........... ........... ........... ........... ...........
trach.
L8600.............. Implant breast silicone/eq .................. N................. ........... ........... ........... ........... ...........
L8603.............. Collagen imp urinary 2.5 .................. N................. ........... ........... ........... ........... ...........
ml.
L8606.............. Synthetic implnt urinary .................. N................. ........... ........... ........... ........... ...........
1ml.
L8609.............. Artificial cornea......... .................. N................. ........... ........... ........... ........... ...........
L8610.............. Ocular implant............ .................. N................. ........... ........... ........... ........... ...........
L8612.............. Aqueous shunt prosthesis.. .................. N................. ........... ........... ........... ........... ...........
L8613.............. Ossicular implant......... .................. N................. ........... ........... ........... ........... ...........
L8614.............. Cochlear device........... .................. N................. ........... ........... ........... ........... ...........
L8615.............. Coch implant headset .................. A................. ........... ........... ........... ........... ...........
replace.
L8616.............. Coch implant microphone .................. A................. ........... ........... ........... ........... ...........
repl.
L8617.............. Coch implant trans coil .................. A................. ........... ........... ........... ........... ...........
repl.
L8618.............. Coch implant tran cable .................. A................. ........... ........... ........... ........... ...........
repl.
L8619.............. Replace cochlear processor .................. A................. ........... ........... ........... ........... ...........
L8621.............. Repl zinc air battery..... .................. A................. ........... ........... ........... ........... ...........
L8622.............. Repl alkaline battery..... .................. A................. ........... ........... ........... ........... ...........
[[Page 67160]]
L8623.............. Lith ion batt CID,non- .................. A................. ........... ........... ........... ........... ...........
earlvl.
L8624.............. Lith ion batt CID, ear .................. A................. ........... ........... ........... ........... ...........
level.
L8630.............. Metacarpophalangeal .................. N................. ........... ........... ........... ........... ...........
implant.
L8631.............. MCP joint repl 2 pc or .................. N................. ........... ........... ........... ........... ...........
more.
L8641.............. Metatarsal joint implant.. .................. N................. ........... ........... ........... ........... ...........
L8642.............. Hallux implant............ .................. N................. ........... ........... ........... ........... ...........
L8658.............. Interphalangeal joint .................. N................. ........... ........... ........... ........... ...........
spacer.
L8659.............. Interphalangeal joint repl .................. N................. ........... ........... ........... ........... ...........
L8670.............. Vascular graft, synthetic. .................. N................. ........... ........... ........... ........... ...........
L8680.............. Implt neurostim elctr each .................. B................. ........... ........... ........... ........... ...........
L8681.............. Pt prgrm for implt .................. A................. ........... ........... ........... ........... ...........
neurostim.
L8682.............. Implt neurostim radiofq .................. N................. ........... ........... ........... ........... ...........
rec.
L8683.............. Radiofq trsmtr for implt .................. A................. ........... ........... ........... ........... ...........
neu.
L8684.............. Radiof trsmtr implt scrl .................. A................. ........... ........... ........... ........... ...........
neu.
L8685.............. Implt nrostm pls gen sng .................. B................. ........... ........... ........... ........... ...........
rec.
L8686.............. Implt nrostm pls gen sng .................. B................. ........... ........... ........... ........... ...........
non.
L8687.............. Implt nrostm pls gen dua .................. B................. ........... ........... ........... ........... ...........
rec.
L8688.............. Implt nrostm pls gen dua .................. B................. ........... ........... ........... ........... ...........
non.
L8689.............. External recharg sys .................. A................. ........... ........... ........... ........... ...........
intern.
L8690.............. Aud osseo dev, int/ext .................. H................. 1032 ........... ........... ........... ...........
comp.
L8691.............. Aud osseo dev ext snd .................. A................. ........... ........... ........... ........... ...........
proces.
L8695.............. External recharg sys .................. A................. ........... ........... ........... ........... ...........
extern.
L8699.............. Prosthetic implant NOS.... .................. N................. ........... ........... ........... ........... ...........
L9900.............. O&P supply/accessory/ .................. A................. ........... ........... ........... ........... ...........
service.
M0064.............. Visit for drug monitoring. CH................ Q................. 0606 1.3226 $84.24 ........... $16.85
M0075.............. Cellular therapy.......... .................. E................. ........... ........... ........... ........... ...........
M0076.............. Prolotherapy.............. .................. E................. ........... ........... ........... ........... ...........
M0100.............. Intragastric hypothermia.. .................. E................. ........... ........... ........... ........... ...........
M0300.............. IV chelationtherapy....... .................. E................. ........... ........... ........... ........... ...........
M0301.............. Fabric wrapping of .................. E................. ........... ........... ........... ........... ...........
aneurysm.
P2028.............. Cephalin floculation test. .................. A................. ........... ........... ........... ........... ...........
P2029.............. Congo red blood test...... .................. A................. ........... ........... ........... ........... ...........
P2031.............. Hair analysis............. .................. E................. ........... ........... ........... ........... ...........
P2033.............. Blood thymol turbidity.... .................. A................. ........... ........... ........... ........... ...........
P2038.............. Blood mucoprotein......... .................. A................. ........... ........... ........... ........... ...........
P3000.............. Screen pap by tech w md .................. A................. ........... ........... ........... ........... ...........
supv.
P3001.............. Screening pap smear by .................. B................. ........... ........... ........... ........... ...........
phys.
P7001.............. Culture bacterial urine... .................. E................. ........... ........... ........... ........... ...........
P9010.............. Whole blood for .................. K................. 0950 4.0011 $254.85 ........... $50.97
transfusion.
P9011.............. Blood split unit.......... .................. K................. 0967 2.3409 $149.10 ........... $29.82
P9012.............. Cryoprecipitate each unit. .................. K................. 0952 0.6474 $41.24 ........... $8.25
P9016.............. RBC leukocytes reduced.... .................. K................. 0954 2.9069 $185.15 ........... $37.03
P9017.............. Plasma 1 donor frz w/in 8 .................. K................. 9508 1.0524 $67.03 ........... $13.41
hr.
P9019.............. Platelets, each unit...... .................. K................. 0957 1.0911 $69.50 ........... $13.90
P9020.............. Plaelet rich plasma unit.. .................. K................. 0958 5.7070 $363.50 ........... $72.70
P9021.............. Red blood cells unit...... .................. K................. 0959 2.0356 $129.66 ........... $25.93
P9022.............. Washed red blood cells .................. K................. 0960 4.3494 $277.03 ........... $55.41
unit.
P9023.............. Frozen plasma, pooled, sd. .................. K................. 0949 1.1598 $73.87 ........... $14.77
P9031.............. Platelets leukocytes .................. K................. 1013 1.6879 $107.51 ........... $21.50
reduced.
P9032.............. Platelets, irradiated..... .................. K................. 9500 1.9110 $121.72 ........... $24.34
P9033.............. Platelets leukoreduced .................. K................. 0968 2.1971 $139.94 ........... $27.99
irrad.
P9034.............. Platelets, pheresis....... .................. K................. 9507 6.9242 $441.03 ........... $88.21
P9035.............. Platelet pheres .................. K................. 9501 7.8426 $499.53 ........... $99.91
leukoreduced.
P9036.............. Platelet pheresis .................. K................. 9502 6.5581 $417.71 ........... $83.54
irradiated.
P9037.............. Plate pheres leukoredu .................. K................. 1019 9.8923 $630.08 ........... $126.02
irrad.
P9038.............. RBC irradiated............ .................. K................. 9505 3.0643 $195.18 ........... $39.04
P9039.............. RBC deglycerolized........ .................. K................. 9504 5.4516 $347.23 ........... $69.45
P9040.............. RBC leukoreduced .................. K................. 0969 3.7722 $240.27 ........... $48.05
irradiated.
P9041.............. Albumin (human),5%, 50ml.. .................. K................. 0961 0.3413 $21.74 ........... $4.35
P9043.............. Plasma protein .................. K................. 0956 1.4739 $93.88 ........... $18.78
fract,5%,50ml.
P9044.............. Cryoprecipitatereducedplas .................. K................. 1009 1.3139 $83.69 ........... $16.74
ma.
P9045.............. Albumin (human), 5%, 250 .................. K................. 0963 1.0987 $69.98 ........... $14.00
ml.
P9046.............. Albumin (human), 25%, 20 .................. K................. 0964 0.4118 $26.23 ........... $5.25
ml.
P9047.............. Albumin (human), 25%, 50ml .................. K................. 0965 1.1362 $72.37 ........... $14.47
P9048.............. Plasmaprotein .................. K................. 0966 3.3792 $215.23 ........... $43.05
fract,5%,250ml.
P9050.............. Granulocytes, pheresis .................. K................. 9506 21.7847 $1,387.55 ........... $277.51
unit.
P9051.............. Blood, l/r, cmv-neg....... .................. K................. 1010 2.3221 $147.90 ........... $29.58
P9052.............. Platelets, hla-m, l/r, .................. K................. 1011 10.1413 $645.94 ........... $129.19
unit.
P9053.............. Plt, pher, l/r cmv-neg, .................. K................. 1020 10.7787 $686.54 ........... $137.31
irr.
P9054.............. Blood, l/r, froz/degly/ .................. K................. 1016 3.4353 $218.81 ........... $43.76
wash.
P9055.............. Plt, aph/pher, l/r, cmv- .................. K................. 1017 7.6733 $488.74 ........... $97.75
neg.
P9056.............. Blood, l/r, irradiated.... .................. K................. 1018 2.3099 $147.13 ........... $29.43
P9057.............. RBC, frz/deg/wsh, l/r, .................. K................. 1021 5.8716 $373.99 ........... $74.80
irrad.
P9058.............. RBC, l/r, cmv-neg, irrad.. .................. K................. 1022 4.1363 $263.46 ........... $52.69
P9059.............. Plasma, frz between 8- .................. K................. 0955 1.2235 $77.93 ........... $15.59
24hour.
P9060.............. Fr frz plasma donor .................. K................. 9503 0.8264 $52.64 ........... $10.53
retested.
P9603.............. One-way allow prorated .................. A................. ........... ........... ........... ........... ...........
miles.
P9604.............. One-way allow prorated .................. A................. ........... ........... ........... ........... ...........
trip.
P9612.............. Catheterize for urine spec .................. A................. ........... ........... ........... ........... ...........
P9615.............. Urine specimen collect .................. N................. ........... ........... ........... ........... ...........
mult.
[[Page 67161]]
Q0035.............. Cardiokymography.......... .................. X................. 0100 2.5547 $162.72 $41.44 $32.54
Q0081.............. Infusion ther other than .................. B................. ........... ........... ........... ........... ...........
che.
Q0083.............. Chemo by other than .................. B................. ........... ........... ........... ........... ...........
infusion.
Q0084.............. Chemotherapy by infusion.. .................. B................. ........... ........... ........... ........... ...........
Q0085.............. Chemo by both infusion and .................. B................. ........... ........... ........... ........... ...........
o.
Q0091.............. Obtaining screen pap smear .................. T................. 0191 0.1309 $8.34 $2.36 $1.67
Q0092.............. Set up port xray equipment .................. N................. ........... ........... ........... ........... ...........
Q0111.............. Wet mounts/ w preparations .................. A................. ........... ........... ........... ........... ...........
Q0112.............. Potassium hydroxide preps. .................. A................. ........... ........... ........... ........... ...........
Q0113.............. Pinworm examinations...... .................. A................. ........... ........... ........... ........... ...........
Q0114.............. Fern test................. .................. A................. ........... ........... ........... ........... ...........
Q0115.............. Post-coital mucous exam... .................. A................. ........... ........... ........... ........... ...........
Q0144.............. Azithromycin dihydrate, .................. E................. ........... ........... ........... ........... ...........
oral.
Q0163.............. Diphenhydramine HCl 50mg.. .................. N................. ........... ........... ........... ........... ...........
Q0164.............. Prochlorperazine maleate .................. N................. ........... ........... ........... ........... ...........
5mg.
Q0165.............. Prochlorperazine .................. B................. ........... ........... ........... ........... ...........
maleate10mg.
Q0166.............. Granisetron HCl 1 mg oral. .................. K................. 0765 ........... $49.96 ........... $9.99
Q0167.............. Dronabinol 2.5mg oral..... .................. N................. ........... ........... ........... ........... ...........
Q0168.............. Dronabinol 5mg oral....... .................. B................. ........... ........... ........... ........... ...........
Q0169.............. Promethazine HCl 12.5mg .................. N................. ........... ........... ........... ........... ...........
oral.
Q0170.............. Promethazine HCl 25 mg .................. B................. ........... ........... ........... ........... ...........
oral.
Q0171.............. Chlorpromazine HCl 10mg .................. N................. ........... ........... ........... ........... ...........
oral.
Q0172.............. Chlorpromazine HCl 25mg .................. B................. ........... ........... ........... ........... ...........
oral.
Q0173.............. Trimethobenzamide HCl .................. N................. ........... ........... ........... ........... ...........
250mg.
Q0174.............. Thiethylperazine .................. N................. ........... ........... ........... ........... ...........
maleate10mg.
Q0175.............. Perphenazine 4mg oral..... .................. N................. ........... ........... ........... ........... ...........
Q0176.............. Perphenazine 8mg oral..... .................. B................. ........... ........... ........... ........... ...........
Q0177.............. Hydroxyzine pamoate 25mg.. .................. N................. ........... ........... ........... ........... ...........
Q0178.............. Hydroxyzine pamoate 50mg.. .................. B................. ........... ........... ........... ........... ...........
Q0179.............. Ondansetron HCl 8mg oral.. .................. K................. 0769 ........... $18.37 ........... $3.67
Q0180.............. Dolasetron mesylate oral.. .................. K................. 0763 ........... $43.77 ........... $8.75
Q0181.............. Unspecified oral anti- .................. E................. ........... ........... ........... ........... ...........
emetic.
Q0480.............. Driver pneumatic vad, rep. .................. A................. ........... ........... ........... ........... ...........
Q0481.............. Microprcsr cu elec vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0482.............. Microprcsr cu combo vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0483.............. Monitor elec vad, rep..... .................. A................. ........... ........... ........... ........... ...........
Q0484.............. Monitor elec or comb vad .................. A................. ........... ........... ........... ........... ...........
rep.
Q0485.............. Monitor cable elec vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0486.............. Mon cable elec/pneum vad .................. A................. ........... ........... ........... ........... ...........
rep.
Q0487.............. Leads any type vad, rep .................. A................. ........... ........... ........... ........... ...........
only.
Q0488.............. Pwr pack base elec vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0489.............. Pwr pck base combo vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0490.............. Emr pwr source elec vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0491.............. Emr pwr source combo vad .................. A................. ........... ........... ........... ........... ...........
rep.
Q0492.............. Emr pwr cbl elec vad, rep. .................. A................. ........... ........... ........... ........... ...........
Q0493.............. Emr pwr cbl combo vad, rep .................. A................. ........... ........... ........... ........... ...........
Q0494.............. Emr hd pmp elec/combo, rep .................. A................. ........... ........... ........... ........... ...........
Q0495.............. Charger elec/combo vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0496.............. Battery elec/combo vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0497.............. Bat clps elec/comb vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0498.............. Holster elec/combo vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0499.............. Belt/vest elec/combo vad .................. A................. ........... ........... ........... ........... ...........
rep.
Q0500.............. Filters elec/combo vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0501.............. Shwr cov elec/combo vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0502.............. Mobility cart pneum vad, .................. A................. ........... ........... ........... ........... ...........
rep.
Q0503.............. Battery pneum vad .................. A................. ........... ........... ........... ........... ...........
replacemnt.
Q0504.............. Pwr adpt pneum vad, rep .................. A................. ........... ........... ........... ........... ...........
veh.
Q0505.............. Miscl supply/accessory vad .................. A................. ........... ........... ........... ........... ...........
Q0510.............. Dispens fee .................. B................. ........... ........... ........... ........... ...........
immunosupressive.
Q0511.............. Sup fee .................. B................. ........... ........... ........... ........... ...........
antiem,antica,immuno.
Q0512.............. Px sup fee anti-can sub .................. B................. ........... ........... ........... ........... ...........
pres.
Q0513.............. Disp fee inhal drugs/30 .................. B................. ........... ........... ........... ........... ...........
days.
Q0514.............. Disp fee inhal drugs/90 .................. B................. ........... ........... ........... ........... ...........
days.
Q0515.............. Sermorelin acetate .................. K................. 3050 ........... $1.74 ........... $0.35
injection.
Q1003.............. Ntiol category 3.......... .................. N................. ........... ........... ........... ........... ...........
Q1004.............. Ntiol category 4.......... CH................ E................. ........... ........... ........... ........... ...........
Q1005.............. Ntiol category 5.......... CH................ E................. ........... ........... ........... ........... ...........
Q2004.............. Bladder calculi irrig sol. .................. N................. ........... ........... ........... ........... ...........
Q2009.............. Fosphenytoin, 50 mg....... .................. K................. 7028 ........... $5.76 ........... $1.15
Q2017.............. Teniposide, 50 mg......... .................. K................. 7035 ........... $280.26 ........... $56.05
Q3001.............. Brachytherapy .................. B................. ........... ........... ........... ........... ...........
Radioelements.
Q3014.............. Telehealth facility fee... .................. A................. ........... ........... ........... ........... ...........
Q3025.............. IM inj interferon beta 1-a .................. K................. 9022 ........... $118.84 ........... $23.77
Q3026.............. Subc inj interferon beta- .................. E................. ........... ........... ........... ........... ...........
1a.
Q3031.............. Collagen skin test........ .................. N................. ........... ........... ........... ........... ...........
Q4001.............. Cast sup body cast plaster .................. B................. ........... ........... ........... ........... ...........
Q4002.............. Cast sup body cast .................. B................. ........... ........... ........... ........... ...........
fiberglas.
Q4003.............. Cast sup shoulder cast .................. B................. ........... ........... ........... ........... ...........
plstr.
Q4004.............. Cast sup shoulder cast .................. B................. ........... ........... ........... ........... ...........
fbrgl.
Q4005.............. Cast sup long arm adult .................. B................. ........... ........... ........... ........... ...........
plst.
[[Page 67162]]
Q4006.............. Cast sup long arm adult .................. B................. ........... ........... ........... ........... ...........
fbrg.
Q4007.............. Cast sup long arm ped .................. B................. ........... ........... ........... ........... ...........
plster.
Q4008.............. Cast sup long arm ped .................. B................. ........... ........... ........... ........... ...........
fbrgls.
Q4009.............. Cast sup sht arm adult .................. B................. ........... ........... ........... ........... ...........
plstr.
Q4010.............. Cast sup sht arm adult .................. B................. ........... ........... ........... ........... ...........
fbrgl.
Q4011.............. Cast sup sht arm ped .................. B................. ........... ........... ........... ........... ...........
plaster.
Q4012.............. Cast sup sht arm ped .................. B................. ........... ........... ........... ........... ...........
fbrglas.
Q4013.............. Cast sup gauntlet plaster. .................. B................. ........... ........... ........... ........... ...........
Q4014.............. Cast sup gauntlet .................. B................. ........... ........... ........... ........... ...........
fiberglass.
Q4015.............. Cast sup gauntlet ped .................. B................. ........... ........... ........... ........... ...........
plster.
Q4016.............. Cast sup gauntlet ped .................. B................. ........... ........... ........... ........... ...........
fbrgls.
Q4017.............. Cast sup lng arm splint .................. B................. ........... ........... ........... ........... ...........
plst.
Q4018.............. Cast sup lng arm splint .................. B................. ........... ........... ........... ........... ...........
fbrg.
Q4019.............. Cast sup lng arm splnt ped .................. B................. ........... ........... ........... ........... ...........
p.
Q4020.............. Cast sup lng arm splnt ped .................. B................. ........... ........... ........... ........... ...........
f.
Q4021.............. Cast sup sht arm splint .................. B................. ........... ........... ........... ........... ...........
plst.
Q4022.............. Cast sup sht arm splint .................. B................. ........... ........... ........... ........... ...........
fbrg.
Q4023.............. Cast sup sht arm splnt ped .................. B................. ........... ........... ........... ........... ...........
p.
Q4024.............. Cast sup sht arm splnt ped .................. B................. ........... ........... ........... ........... ...........
f.
Q4025.............. Cast sup hip spica plaster .................. B................. ........... ........... ........... ........... ...........
Q4026.............. Cast sup hip spica .................. B................. ........... ........... ........... ........... ...........
fiberglas.
Q4027.............. Cast sup hip spica ped .................. B................. ........... ........... ........... ........... ...........
plstr.
Q4028.............. Cast sup hip spica ped .................. B................. ........... ........... ........... ........... ...........
fbrgl.
Q4029.............. Cast sup long leg plaster. .................. B................. ........... ........... ........... ........... ...........
Q4030.............. Cast sup long leg .................. B................. ........... ........... ........... ........... ...........
fiberglass.
Q4031.............. Cast sup lng leg ped .................. B................. ........... ........... ........... ........... ...........
plaster.
Q4032.............. Cast sup lng leg ped .................. B................. ........... ........... ........... ........... ...........
fbrgls.
Q4033.............. Cast sup lng leg cylinder .................. B................. ........... ........... ........... ........... ...........
pl.
Q4034.............. Cast sup lng leg cylinder .................. B................. ........... ........... ........... ........... ...........
fb.
Q4035.............. Cast sup lngleg cylndr ped .................. B................. ........... ........... ........... ........... ...........
p.
Q4036.............. Cast sup lngleg cylndr ped .................. B................. ........... ........... ........... ........... ...........
f.
Q4037.............. Cast sup shrt leg plaster. .................. B................. ........... ........... ........... ........... ...........
Q4038.............. Cast sup shrt leg .................. B................. ........... ........... ........... ........... ...........
fiberglass.
Q4039.............. Cast sup shrt leg ped .................. B................. ........... ........... ........... ........... ...........
plster.
Q4040.............. Cast sup shrt leg ped .................. B................. ........... ........... ........... ........... ...........
fbrgls.
Q4041.............. Cast sup lng leg splnt .................. B................. ........... ........... ........... ........... ...........
plstr.
Q4042.............. Cast sup lng leg splnt .................. B................. ........... ........... ........... ........... ...........
fbrgl.
Q4043.............. Cast sup lng leg splnt ped .................. B................. ........... ........... ........... ........... ...........
p.
Q4044.............. Cast sup lng leg splnt ped .................. B................. ........... ........... ........... ........... ...........
f.
Q4045.............. Cast sup sht leg splnt .................. B................. ........... ........... ........... ........... ...........
plstr.
Q4046.............. Cast sup sht leg splnt .................. B................. ........... ........... ........... ........... ...........
fbrgl.
Q4047.............. Cast sup sht leg splnt ped .................. B................. ........... ........... ........... ........... ...........
p.
Q4048.............. Cast sup sht leg splnt ped .................. B................. ........... ........... ........... ........... ...........
f.
Q4049.............. Finger splint, static..... .................. B................. ........... ........... ........... ........... ...........
Q4050.............. Cast supplies unlisted.... .................. B................. ........... ........... ........... ........... ...........
Q4051.............. Splint supplies misc...... .................. B................. ........... ........... ........... ........... ...........
Q4079.............. Natalizumab injection..... CH................ D................. ........... ........... ........... ........... ...........
Q4080.............. Iloprost non-comp unit .................. Y................. ........... ........... ........... ........... ...........
dose.
Q4081.............. Epoetin alfa, 100 units .................. A................. ........... ........... ........... ........... ...........
ESRD.
Q4082.............. Drug/bio NOC part B drug .................. B................. ........... ........... ........... ........... ...........
CAP.
Q4083.............. Hyalgan/supartz inj per CH................ D................. ........... ........... ........... ........... ...........
dose.
Q4084.............. Synvisc inj per dose...... CH................ D................. ........... ........... ........... ........... ...........
Q4085.............. Euflexxa inj per dose..... CH................ D................. ........... ........... ........... ........... ...........
Q4086.............. Orthovisc inj per dose.... CH................ D................. ........... ........... ........... ........... ...........
Q4087.............. Octagam injection......... CH................ D................. ........... ........... ........... ........... ...........
Q4088.............. Gammagard liquid injection CH................ D................. ........... ........... ........... ........... ...........
Q4089.............. Rhophylac injection....... CH................ D................. ........... ........... ........... ........... ...........
Q4090.............. HepaGam B IM injection.... CH................ D................. ........... ........... ........... ........... ...........
Q4091.............. Flebogamma injection...... CH................ D................. ........... ........... ........... ........... ...........
Q4092.............. Gamunex injection......... CH................ D................. ........... ........... ........... ........... ...........
Q4093.............. Albuterol inh non-comp con CH................ D................. ........... ........... ........... ........... ...........
Q4094.............. Albuterol inh non-comp u d CH................ D................. ........... ........... ........... ........... ...........
Q4095.............. Reclast injection......... CH................ D................. ........... ........... ........... ........... ...........
Q5001.............. Hospice in patient home... .................. B................. ........... ........... ........... ........... ...........
Q5002.............. Hospice in assisted living .................. B................. ........... ........... ........... ........... ...........
Q5003.............. Hospice in LT/non-skilled .................. B................. ........... ........... ........... ........... ...........
NF.
Q5004.............. Hospice in SNF............ .................. B................. ........... ........... ........... ........... ...........
Q5005.............. Hospice, inpatient .................. B................. ........... ........... ........... ........... ...........
hospital.
Q5006.............. Hospice in hospice .................. B................. ........... ........... ........... ........... ...........
facility.
Q5007.............. Hospice in LTCH........... .................. B................. ........... ........... ........... ........... ...........
Q5008.............. Hospice in inpatient psych .................. B................. ........... ........... ........... ........... ...........
Q5009.............. Hospice care, NOS......... .................. B................. ........... ........... ........... ........... ...........
Q9945.............. LOCM <=149 mg/ml iodine, CH................ D................. ........... ........... ........... ........... ...........
1ml.
Q9946.............. LOCM 150-199mg/ml CH................ D................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9947.............. LOCM 200-249mg/ml CH................ D................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9948.............. LOCM 250-299mg/ml CH................ D................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9949.............. LOCM 300-349mg/ml CH................ D................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9950.............. LOCM 350-399mg/ml CH................ D................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9951.............. LOCM >= 400 mg/ml CH................ N................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9952.............. Inj Gad-base MR CH................ D................. ........... ........... ........... ........... ...........
contrast,1ml.
[[Page 67163]]
Q9953.............. Inj Fe-based MR CH................ N................. ........... ........... ........... ........... ...........
contrast,1ml.
Q9954.............. Oral MR contrast, 100 ml.. CH................ N................. ........... ........... ........... ........... ...........
Q9955.............. Inj perflexane lip CH................ N................. ........... ........... ........... ........... ...........
micros,ml.
Q9956.............. Inj octafluoropropane CH................ N................. ........... ........... ........... ........... ...........
mic,ml.
Q9957.............. Inj perflutren lip CH................ N................. ........... ........... ........... ........... ...........
micros,ml.
Q9958.............. HOCM <=149 mg/ml iodine, .................. N................. ........... ........... ........... ........... ...........
1ml.
Q9959.............. HOCM 150-199mg/ml .................. N................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9960.............. HOCM 200-249mg/ml .................. N................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9961.............. HOCM 250-299mg/ml .................. N................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9962.............. HOCM 300-349mg/ml .................. N................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9963.............. HOCM 350-399mg/ml .................. N................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9964.............. HOCM>= 400mg/ml iodine, .................. N................. ........... ........... ........... ........... ...........
1ml.
Q9965.............. LOCM 100-199mg/ml NI................ N................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9966.............. LOCM 200-299mg/ml NI................ N................. ........... ........... ........... ........... ...........
iodine,1ml.
Q9967.............. LOCM 300-399mg/ml NI................ N................. ........... ........... ........... ........... ...........
iodine,1ml.
R0070.............. Transport portable x-ray.. .................. B................. ........... ........... ........... ........... ...........
R0075.............. Transport port x-ray .................. B................. ........... ........... ........... ........... ...........
multipl.
R0076.............. Transport portable EKG.... .................. B................. ........... ........... ........... ........... ...........
V2020.............. Vision svcs frames .................. A................. ........... ........... ........... ........... ...........
purchases.
V2025.............. Eyeglasses delux frames... .................. E................. ........... ........... ........... ........... ...........
V2100.............. Lens spher single plano .................. A................. ........... ........... ........... ........... ...........
4.00.
V2101.............. Single visn sphere 4.12- .................. A................. ........... ........... ........... ........... ...........
7.00.
V2102.............. Singl visn sphere 7.12- .................. A................. ........... ........... ........... ........... ...........
20.00.
V2103.............. Spherocylindr 4.00d/12- .................. A................. ........... ........... ........... ........... ...........
2.00d.
V2104.............. Spherocylindr 4.00d/2.12- .................. A................. ........... ........... ........... ........... ...........
4d.
V2105.............. Spherocylinder 4.00d/4.25- .................. A................. ........... ........... ........... ........... ...........
6d.
V2106.............. Spherocylinder 4.00d/ .................. A................. ........... ........... ........... ........... ...........
>6.00d.
V2107.............. Spherocylinder 4.25d/12-2d .................. A................. ........... ........... ........... ........... ...........
V2108.............. Spherocylinder 4.25d/2.12- .................. A................. ........... ........... ........... ........... ...........
4d.
V2109.............. Spherocylinder 4.25d/4.25- .................. A................. ........... ........... ........... ........... ...........
6d.
V2110.............. Spherocylinder 4.25d/over .................. A................. ........... ........... ........... ........... ...........
6d.
V2111.............. Spherocylindr 7.25d/.25- .................. A................. ........... ........... ........... ........... ...........
2.25.
V2112.............. Spherocylindr 7.25d/2.25- .................. A................. ........... ........... ........... ........... ...........
4d.
V2113.............. Spherocylindr 7.25d/4.25- .................. A................. ........... ........... ........... ........... ...........
6d.
V2114.............. Spherocylinder over 12.00d .................. A................. ........... ........... ........... ........... ...........
V2115.............. Lens lenticular bifocal... .................. A................. ........... ........... ........... ........... ...........
V2118.............. Lens aniseikonic single... .................. A................. ........... ........... ........... ........... ...........
V2121.............. Lenticular lens, single... .................. A................. ........... ........... ........... ........... ...........
V2199.............. Lens single vision not oth .................. A................. ........... ........... ........... ........... ...........
c.
V2200.............. Lens spher bifoc plano .................. A................. ........... ........... ........... ........... ...........
4.00d.
V2201.............. Lens sphere bifocal 4.12- .................. A................. ........... ........... ........... ........... ...........
7.0.
V2202.............. Lens sphere bifocal 7.12- .................. A................. ........... ........... ........... ........... ...........
20.
V2203.............. Lens sphcyl bifocal 4.00d/ .................. A................. ........... ........... ........... ........... ...........
.1.
V2204.............. Lens sphcy bifocal 4.00d/ .................. A................. ........... ........... ........... ........... ...........
2.1.
V2205.............. Lens sphcy bifocal 4.00d/ .................. A................. ........... ........... ........... ........... ...........
4.2.
V2206.............. Lens sphcy bifocal 4.00d/ .................. A................. ........... ........... ........... ........... ...........
ove.
V2207.............. Lens sphcy bifocal 4.25-7d/ .................. A................. ........... ........... ........... ........... ...........
.
V2208.............. Lens sphcy bifocal 4.25-7/ .................. A................. ........... ........... ........... ........... ...........
2.
V2209.............. Lens sphcy bifocal 4.25-7/ .................. A................. ........... ........... ........... ........... ...........
4.
V2210.............. Lens sphcy bifocal 4.25-7/ .................. A................. ........... ........... ........... ........... ...........
ov.
V2211.............. Lens sphcy bifo 7.25-12/ .................. A................. ........... ........... ........... ........... ...........
.25-.
V2212.............. Lens sphcyl bifo 7.25-12/ .................. A................. ........... ........... ........... ........... ...........
2.2.
V2213.............. Lens sphcyl bifo 7.25-12/ .................. A................. ........... ........... ........... ........... ...........
4.2.
V2214.............. Lens sphcyl bifocal over .................. A................. ........... ........... ........... ........... ...........
12.
V2215.............. Lens lenticular bifocal... .................. A................. ........... ........... ........... ........... ...........
V2218.............. Lens aniseikonic bifocal.. .................. A................. ........... ........... ........... ........... ...........
V2219.............. Lens bifocal seg width .................. A................. ........... ........... ........... ........... ...........
over.
V2220.............. Lens bifocal add over .................. A................. ........... ........... ........... ........... ...........
3.25d.
V2221.............. Lenticular lens, bifocal.. .................. A................. ........... ........... ........... ........... ...........
V2299.............. Lens bifocal speciality... .................. A................. ........... ........... ........... ........... ...........
V2300.............. Lens sphere trifocal 4.00d .................. A................. ........... ........... ........... ........... ...........
V2301.............. Lens sphere trifocal 4.12- .................. A................. ........... ........... ........... ........... ...........
7.
V2302.............. Lens sphere trifocal 7.12- .................. A................. ........... ........... ........... ........... ...........
20.
V2303.............. Lens sphcy trifocal 4.0/ .................. A................. ........... ........... ........... ........... ...........
.12-.
V2304.............. Lens sphcy trifocal 4.0/ .................. A................. ........... ........... ........... ........... ...........
2.25.
V2305.............. Lens sphcy trifocal 4.0/ .................. A................. ........... ........... ........... ........... ...........
4.25.
V2306.............. Lens sphcyl trifocal 4.00/ .................. A................. ........... ........... ........... ........... ...........
>6.
V2307.............. Lens sphcy trifocal 4.25-7/ .................. A................. ........... ........... ........... ........... ...........
.
V2308.............. Lens sphc trifocal 4.25-7/ .................. A................. ........... ........... ........... ........... ...........
2.
V2309.............. Lens sphc trifocal 4.25-7/ .................. A................. ........... ........... ........... ........... ...........
4.
V2310.............. Lens sphc trifocal 4.25-7/ .................. A................. ........... ........... ........... ........... ...........
>6.
V2311.............. Lens sphc trifo 7.25-12/ .................. A................. ........... ........... ........... ........... ...........
.25-.
V2312.............. Lens sphc trifo 7.25-12/ .................. A................. ........... ........... ........... ........... ...........
2.25.
V2313.............. Lens sphc trifo 7.25-12/ .................. A................. ........... ........... ........... ........... ...........
4.25.
V2314.............. Lens sphcyl trifocal over .................. A................. ........... ........... ........... ........... ...........
12.
V2315.............. Lens lenticular trifocal.. .................. A................. ........... ........... ........... ........... ...........
V2318.............. Lens aniseikonic trifocal. .................. A................. ........... ........... ........... ........... ...........
V2319.............. Lens trifocal seg width > .................. A................. ........... ........... ........... ........... ...........
28.
V2320.............. Lens trifocal add over .................. A................. ........... ........... ........... ........... ...........
3.25d.
V2321.............. Lenticular lens, trifocal. .................. A................. ........... ........... ........... ........... ...........
[[Page 67164]]
V2399.............. Lens trifocal speciality.. .................. A................. ........... ........... ........... ........... ...........
V2410.............. Lens variab asphericity .................. A................. ........... ........... ........... ........... ...........
sing.
V2430.............. Lens variable asphericity .................. A................. ........... ........... ........... ........... ...........
bi.
V2499.............. Variable asphericity lens. .................. A................. ........... ........... ........... ........... ...........
V2500.............. Contact lens pmma .................. A................. ........... ........... ........... ........... ...........
spherical.
V2501.............. Cntct lens pmma-toric/ .................. A................. ........... ........... ........... ........... ...........
prism.
V2502.............. Contact lens pmma bifocal. .................. A................. ........... ........... ........... ........... ...........
V2503.............. Cntct lens pmma color .................. A................. ........... ........... ........... ........... ...........
vision.
V2510.............. Cntct gas permeable .................. A................. ........... ........... ........... ........... ...........
sphericl.
V2511.............. Cntct toric prism ballast. .................. A................. ........... ........... ........... ........... ...........
V2512.............. Cntct lens gas permbl .................. A................. ........... ........... ........... ........... ...........
bifocl.
V2513.............. Contact lens extended wear .................. A................. ........... ........... ........... ........... ...........
V2520.............. Contact lens hydrophilic.. .................. A................. ........... ........... ........... ........... ...........
V2521.............. Cntct lens hydrophilic .................. A................. ........... ........... ........... ........... ...........
toric.
V2522.............. Cntct lens hydrophil .................. A................. ........... ........... ........... ........... ...........
bifocl.
V2523.............. Cntct lens hydrophil .................. A................. ........... ........... ........... ........... ...........
extend.
V2530.............. Contact lens gas .................. A................. ........... ........... ........... ........... ...........
impermeable.
V2531.............. Contact lens gas permeable .................. A................. ........... ........... ........... ........... ...........
V2599.............. Contact lens/es other type .................. A................. ........... ........... ........... ........... ...........
V2600.............. Hand held low vision aids. .................. A................. ........... ........... ........... ........... ...........
V2610.............. Single lens spectacle .................. A................. ........... ........... ........... ........... ...........
mount.
V2615.............. Telescop/othr compound .................. A................. ........... ........... ........... ........... ...........
lens.
V2623.............. Plastic eye prosth custom. .................. A................. ........... ........... ........... ........... ...........
V2624.............. Polishing artifical eye... .................. A................. ........... ........... ........... ........... ...........
V2625.............. Enlargemnt of eye .................. A................. ........... ........... ........... ........... ...........
prosthesis.
V2626.............. Reduction of eye .................. A................. ........... ........... ........... ........... ...........
prosthesis.
V2627.............. Scleral cover shell....... .................. A................. ........... ........... ........... ........... ...........
V2628.............. Fabrication & fitting..... .................. A................. ........... ........... ........... ........... ...........
V2629.............. Prosthetic eye other type. .................. A................. ........... ........... ........... ........... ...........
V2630.............. Anter chamber intraocul .................. N................. ........... ........... ........... ........... ...........
lens.
V2631.............. Iris support intraoclr .................. N................. ........... ........... ........... ........... ...........
lens.
V2632.............. Post chmbr intraocular .................. N................. ........... ........... ........... ........... ...........
lens.
V2700.............. Balance lens.............. .................. A................. ........... ........... ........... ........... ...........
V2702.............. Deluxe lens feature....... .................. E................. ........... ........... ........... ........... ...........
V2710.............. Glass/plastic slab off .................. A................. ........... ........... ........... ........... ...........
prism.
V2715.............. Prism lens/es............. .................. A................. ........... ........... ........... ........... ...........
V2718.............. Fresnell prism press-on .................. A................. ........... ........... ........... ........... ...........
lens.
V2730.............. Special base curve........ .................. A................. ........... ........... ........... ........... ...........
V2744.............. Tint photochromatic lens/ .................. A................. ........... ........... ........... ........... ...........
es.
V2745.............. Tint, any color/solid/grad .................. A................. ........... ........... ........... ........... ...........
V2750.............. Anti-reflective coating... .................. A................. ........... ........... ........... ........... ...........
V2755.............. UV lens/es................ .................. A................. ........... ........... ........... ........... ...........
V2756.............. Eye glass case............ .................. E................. ........... ........... ........... ........... ...........
V2760.............. Scratch resistant coating. .................. A................. ........... ........... ........... ........... ...........
V2761.............. Mirror coating............ .................. B................. ........... ........... ........... ........... ...........
V2762.............. Polarization, any lens.... .................. A................. ........... ........... ........... ........... ...........
V2770.............. Occluder lens/es.......... .................. A................. ........... ........... ........... ........... ...........
V2780.............. Oversize lens/es.......... .................. A................. ........... ........... ........... ........... ...........
V2781.............. Progressive lens per lens. .................. B................. ........... ........... ........... ........... ...........
V2782.............. Lens, 1.54-1.65 p/1.60- .................. A................. ........... ........... ........... ........... ...........
1.79g.
V2783.............. Lens, >= 1.66 p/>=1.80 g.. .................. A................. ........... ........... ........... ........... ...........
V2784.............. Lens polycarb or equal.... .................. A................. ........... ........... ........... ........... ...........
V2785.............. Corneal tissue processing. .................. F................. ........... ........... ........... ........... ...........
V2786.............. Occupational multifocal .................. A................. ........... ........... ........... ........... ...........
lens.
V2787.............. Astigmatism-correct NI................ E................. ........... ........... ........... ........... ...........
function.
V2788.............. Presbyopia-correct .................. E................. ........... ........... ........... ........... ...........
function.
V2790.............. Amniotic membrane......... .................. N................. ........... ........... ........... ........... ...........
V2797.............. Vis item/svc in other code .................. A................. ........... ........... ........... ........... ...........
V2799.............. Miscellaneous vision .................. A................. ........... ........... ........... ........... ...........
service.
V5008.............. Hearing screening......... .................. E................. ........... ........... ........... ........... ...........
V5010.............. Assessment for hearing aid .................. E................. ........... ........... ........... ........... ...........
V5011.............. Hearing aid fitting/ .................. E................. ........... ........... ........... ........... ...........
checking.
V5014.............. Hearing aid repair/ .................. E................. ........... ........... ........... ........... ...........
modifying.
V5020.............. Conformity evaluation..... .................. E................. ........... ........... ........... ........... ...........
V5030.............. Body-worn hearing aid air. .................. E................. ........... ........... ........... ........... ...........
V5040.............. Body-worn hearing aid bone .................. E................. ........... ........... ........... ........... ...........
V5050.............. Hearing aid monaural in .................. E................. ........... ........... ........... ........... ...........
ear.
V5060.............. Behind ear hearing aid.... .................. E................. ........... ........... ........... ........... ...........
V5070.............. Glasses air conduction.... .................. E................. ........... ........... ........... ........... ...........
V5080.............. Glasses bone conduction... .................. E................. ........... ........... ........... ........... ...........
V5090.............. Hearing aid dispensing fee .................. E................. ........... ........... ........... ........... ...........
V5095.............. Implant mid ear hearing .................. E................. ........... ........... ........... ........... ...........
pros.
V5100.............. Body-worn bilat hearing .................. E................. ........... ........... ........... ........... ...........
aid.
V5110.............. Hearing aid dispensing fee .................. E................. ........... ........... ........... ........... ...........
V5120.............. Body-worn binaur hearing .................. E................. ........... ........... ........... ........... ...........
aid.
V5130.............. In ear binaural hearing .................. E................. ........... ........... ........... ........... ...........
aid.
V5140.............. Behind ear binaur hearing .................. E................. ........... ........... ........... ........... ...........
ai.
V5150.............. Glasses binaural hearing .................. E................. ........... ........... ........... ........... ...........
aid.
V5160.............. Dispensing fee binaural... .................. E................. ........... ........... ........... ........... ...........
V5170.............. Within ear cros hearing .................. E................. ........... ........... ........... ........... ...........
aid.
[[Page 67165]]
V5180.............. Behind ear cros hearing .................. E................. ........... ........... ........... ........... ...........
aid.
V5190.............. Glasses cros hearing aid.. .................. E................. ........... ........... ........... ........... ...........
V5200.............. Cros hearing aid dispens .................. E................. ........... ........... ........... ........... ...........
fee.
V5210.............. In ear bicros hearing aid. .................. E................. ........... ........... ........... ........... ...........
V5220.............. Behind ear bicros hearing .................. E................. ........... ........... ........... ........... ...........
ai.
V5230.............. Glasses bicros hearing aid .................. E................. ........... ........... ........... ........... ...........
V5240.............. Dispensing fee bicros..... .................. E................. ........... ........... ........... ........... ...........
V5241.............. Dispensing fee, monaural.. .................. E................. ........... ........... ........... ........... ...........
V5242.............. Hearing aid, monaural, cic .................. E................. ........... ........... ........... ........... ...........
V5243.............. Hearing aid, monaural, itc .................. E................. ........... ........... ........... ........... ...........
V5244.............. Hearing aid, prog, mon, .................. E................. ........... ........... ........... ........... ...........
cic.
V5245.............. Hearing aid, prog, mon, .................. E................. ........... ........... ........... ........... ...........
itc.
V5246.............. Hearing aid, prog, mon, .................. E................. ........... ........... ........... ........... ...........
ite.
V5247.............. Hearing aid, prog, mon, .................. E................. ........... ........... ........... ........... ...........
bte.
V5248.............. Hearing aid, binaural, cic .................. E................. ........... ........... ........... ........... ...........
V5249.............. Hearing aid, binaural, itc .................. E................. ........... ........... ........... ........... ...........
V5250.............. Hearing aid, prog, bin, .................. E................. ........... ........... ........... ........... ...........
cic.
V5251.............. Hearing aid, prog, bin, .................. E................. ........... ........... ........... ........... ...........
itc.
V5252.............. Hearing aid, prog, bin, .................. E................. ........... ........... ........... ........... ...........
ite.
V5253.............. Hearing aid, prog, bin, .................. E................. ........... ........... ........... ........... ...........
bte.
V5254.............. Hearing id, digit, mon, .................. E................. ........... ........... ........... ........... ...........
cic.
V5255.............. Hearing aid, digit, mon, .................. E................. ........... ........... ........... ........... ...........
itc.
V5256.............. Hearing aid, digit, mon, .................. E................. ........... ........... ........... ........... ...........
ite.
V5257.............. Hearing aid, digit, mon, .................. E................. ........... ........... ........... ........... ...........
bte.
V5258.............. Hearing aid, digit, bin, .................. E................. ........... ........... ........... ........... ...........
cic.
V5259.............. Hearing aid, digit, bin, .................. E................. ........... ........... ........... ........... ...........
itc.
V5260.............. Hearing aid, digit, bin, .................. E................. ........... ........... ........... ........... ...........
ite.
V5261.............. Hearing aid, digit, bin, .................. E................. ........... ........... ........... ........... ...........
bte.
V5262.............. Hearing aid, disp, .................. E................. ........... ........... ........... ........... ...........
monaural.
V5263.............. Hearing aid, disp, .................. E................. ........... ........... ........... ........... ...........
binaural.
V5264.............. Ear mold/insert........... .................. E................. ........... ........... ........... ........... ...........
V5265.............. Ear mold/insert, disp..... .................. E................. ........... ........... ........... ........... ...........
V5266.............. Battery for hearing device .................. E................. ........... ........... ........... ........... ...........
V5267.............. Hearing aid supply/ .................. E................. ........... ........... ........... ........... ...........
accessory.
V5268.............. ALD Telephone Amplifier... .................. E................. ........... ........... ........... ........... ...........
V5269.............. Alerting device, any type. .................. E................. ........... ........... ........... ........... ...........
V5270.............. ALD, TV amplifier, any .................. E................. ........... ........... ........... ........... ...........
type.
V5271.............. ALD, TV caption decoder... .................. E................. ........... ........... ........... ........... ...........
V5272.............. Tdd....................... .................. E................. ........... ........... ........... ........... ...........
V5273.............. ALD for cochlear implant.. .................. E................. ........... ........... ........... ........... ...........
V5274.............. ALD unspecified........... .................. E................. ........... ........... ........... ........... ...........
V5275.............. Ear impression............ .................. E................. ........... ........... ........... ........... ...........
V5298.............. Hearing aid noc........... .................. E................. ........... ........... ........... ........... ...........
V5299.............. Hearing service........... .................. B................. ........... ........... ........... ........... ...........
V5336.............. Repair communication .................. E................. ........... ........... ........... ........... ...........
device.
V5362.............. Speech screening.......... .................. E................. ........... ........... ........... ........... ...........
V5363.............. Language screening........ .................. E................. ........... ........... ........... ........... ...........
V5364.............. Dysphagia screening....... .................. E................. ........... ........... ........... ........... ...........
--------------------------------------------------------------------------------------------------------------------------------------------------------
Addendum BB.--ASC Covered Ancillary Services Integral to Covered Surgical Procedures for CY 2008
[Including Ancillary Services for Which Payment Is Packaged]
----------------------------------------------------------------------------------------------------------------
CY 2008
HCPCS code Short descriptor Comment indicator Payment indicator payment CY 2008
weight payment
----------------------------------------------------------------------------------------------------------------
0028T.............. Dexa body composition .................. N1................ ........... ...........
study.
0042T.............. Ct perfusion w/contrast, .................. N1................ ........... ...........
cbf.
0054T.............. Bone surgery using CH................ D5................ ........... ...........
computer.
0055T.............. Bone surgery using CH................ D5................ ........... ...........
computer.
0056T.............. Bone surgery using CH................ D5................ ........... ...........
computer.
0067T.............. Ct colonography;dx....... .................. Z2................ 3.0109 $124.65
0071T.............. U/s leiomyomata ablate .................. Z2................ 61.6965 $2,554.30
<200.
0072T.............. U/s leiomyomata ablate .................. Z2................ 61.6965 $2,554.30
>200.
0073T.............. Delivery, comp imrt...... .................. Z2................ 5.4582 $225.97
0126T.............. Chd risk imt study....... .................. N1................ ........... ...........
0144T.............. Ct heart wo dye; qual .................. Z2................ 1.5839 $65.58
calc.
0145T.............. Ct heart w/wo dye funct.. .................. Z2................ 4.7005 $194.61
0146T.............. Ccta w/wo dye............ .................. Z2................ 4.7005 $194.61
0147T.............. Ccta w/wo, quan calcium.. .................. Z2................ 4.7005 $194.61
0148T.............. Ccta w/wo, strxr......... .................. Z2................ 4.7005 $194.61
0149T.............. Ccta w/wo, strxr quan .................. Z2................ 4.7005 $194.61
calc.
0150T.............. Ccta w/wo, disease strxr. .................. Z2................ 4.7005 $194.61
0151T.............. Ct heart funct add-on.... .................. Z2................ 1.5839 $65.58
0159T.............. Cad breast mri........... .................. N1................ ........... ...........
[[Page 67166]]
0174T.............. Cad cxr with interp...... .................. N1................ ........... ...........
0175T.............. Cad cxr remote........... .................. N1................ ........... ...........
0182T.............. Hdr elect brachytherapy.. CH................ Z2................ 27.4752 $1,137.50
0185T.............. Comptr probability NI................ N1................ ........... ...........
analysis.
70010.............. Contrast x-ray of brain.. CH................ N1................ ........... ...........
70015.............. Contrast x-ray of brain.. CH................ N1................ ........... ...........
70030.............. X-ray eye for foreign .................. Z3................ 0.3949 $16.35
body.
70100.............. X-ray exam of jaw........ .................. Z3................ 0.4526 $18.74
70110.............. X-ray exam of jaw........ .................. Z3................ 0.5514 $22.83
70120.............. X-ray exam of mastoids... .................. Z3................ 0.5183 $21.46
70130.............. X-ray exam of mastoids... .................. Z2................ 0.6954 $28.79
70134.............. X-ray exam of middle ear. .................. Z3................ 0.6253 $25.89
70140.............. X-ray exam of facial .................. Z3................ 0.4609 $19.08
bones.
70150.............. X-ray exam of facial .................. Z3................ 0.6336 $26.23
bones.
70160.............. X-ray exam of nasal bones .................. Z3................ 0.4773 $19.76
70170.............. X-ray exam of tear duct.. CH................ N1................ ........... ...........
70190.............. X-ray exam of eye sockets .................. Z3................ 0.5183 $21.46
70200.............. X-ray exam of eye sockets .................. Z3................ 0.6418 $26.57
70210.............. X-ray exam of sinuses.... .................. Z3................ 0.4691 $19.42
70220.............. X-ray exam of sinuses.... .................. Z3................ 0.5925 $24.53
70240.............. X-ray exam, pituitary .................. Z3................ 0.3949 $16.35
saddle.
70250.............. X-ray exam of skull...... .................. Z3................ 0.5101 $21.12
70260.............. X-ray exam of skull...... .................. Z3................ 0.6831 $28.28
70300.............. X-ray exam of teeth...... .................. Z3................ 0.1894 $7.84
70310.............. X-ray exam of teeth...... .................. Z3................ 0.4855 $20.10
70320.............. Full mouth x-ray of teeth .................. Z2................ 0.5749 $23.80
70328.............. X-ray exam of jaw joint.. .................. Z3................ 0.4362 $18.06
70330.............. X-ray exam of jaw joints. CH................ Z2................ 0.6954 $28.79
70332.............. X-ray exam of jaw joint.. CH................ N1................ ........... ...........
70336.............. Magnetic image, jaw joint .................. Z2................ 4.883 $202.16
70350.............. X-ray head for .................. Z3................ 0.2715 $11.24
orthodontia.
70355.............. Panoramic x-ray of jaws.. .................. Z3................ 0.3292 $13.63
70360.............. X-ray exam of neck....... .................. Z3................ 0.3785 $15.67
70370.............. Throat x-ray & .................. Z3................ 1.1768 $48.72
fluoroscopy.
70371.............. Speech evaluation, .................. Z2................ 1.3271 $54.94
complex.
70373.............. Contrast x-ray of larynx. CH................ N1................ ........... ...........
70380.............. X-ray exam of salivary .................. Z3................ 0.5925 $24.53
gland.
70390.............. X-ray exam of salivary CH................ N1................ ........... ...........
duct.
70450.............. Ct head/brain w/o dye.... .................. Z2................ 3.0109 $124.65
70460.............. Ct head/brain w/dye...... .................. Z2................ 4.3564 $180.36
70470.............. Ct head/brain w/o & w/dye .................. Z2................ 5.1125 $211.66
70480.............. Ct orbit/ear/fossa w/o .................. Z2................ 3.0109 $124.65
dye.
70481.............. Ct orbit/ear/fossa w/dye. .................. Z2................ 4.3564 $180.36
70482.............. Ct orbit/ear/fossa w/o&w/ .................. Z2................ 5.1125 $211.66
dye.
70486.............. Ct maxillofacial w/o dye. .................. Z2................ 3.0109 $124.65
70487.............. Ct maxillofacial w/dye... .................. Z2................ 4.3564 $180.36
70488.............. Ct maxillofacial w/o & w/ .................. Z2................ 5.1125 $211.66
dye.
70490.............. Ct soft tissue neck w/o .................. Z2................ 3.0109 $124.65
dye.
70491.............. Ct soft tissue neck w/dye .................. Z2................ 4.3564 $180.36
70492.............. Ct sft tsue nck w/o & w/ .................. Z2................ 5.1125 $211.66
dye.
70496.............. Ct angiography, head..... .................. Z2................ 5.1641 $213.80
70498.............. Ct angiography, neck..... .................. Z2................ 5.1641 $213.80
70540.............. Mri orbit/face/neck w/o .................. Z2................ 5.3933 $223.29
dye.
70542.............. Mri orbit/face/neck w/dye .................. Z2................ 6.235 $258.14
70543.............. Mri orbt/fac/nck w/o & w/ .................. Z2................ 8.2463 $341.41
dye.
70544.............. Mr angiography head w/o .................. Z2................ 5.3933 $223.29
dye.
70545.............. Mr angiography head w/dye .................. Z2................ 6.235 $258.14
70546.............. Mr angiograph head w/o&w/ .................. Z2................ 8.2463 $341.41
dye.
70547.............. Mr angiography neck w/o .................. Z2................ 5.3933 $223.29
dye.
70548.............. Mr angiography neck w/dye .................. Z2................ 6.235 $258.14
70549.............. Mr angiograph neck w/o&w/ .................. Z2................ 8.2463 $341.41
dye.
70551.............. Mri brain w/o dye........ .................. Z2................ 5.3933 $223.29
70552.............. Mri brain w/dye.......... .................. Z2................ 6.235 $258.14
70553.............. Mri brain w/o & w/dye.... .................. Z2................ 8.2463 $341.41
70554.............. Fmri brain by tech....... .................. Z2................ 5.3933 $223.29
70555.............. Fmri brain by phys/psych. .................. Z2................ 5.3933 $223.29
70557.............. Mri brain w/o dye........ .................. Z2................ 5.3933 $223.29
70558.............. Mri brain w/dye.......... .................. Z2................ 6.235 $258.14
[[Page 67167]]
70559.............. Mri brain w/o & w/dye.... .................. Z2................ 8.2463 $341.41
71010.............. Chest x-ray.............. .................. Z3................ 0.3456 $14.31
71015.............. Chest x-ray.............. .................. Z3................ 0.4196 $17.37
71020.............. Chest x-ray.............. .................. Z3................ 0.4609 $19.08
71021.............. Chest x-ray.............. .................. Z3................ 0.5514 $22.83
71022.............. Chest x-ray.............. .................. Z3................ 0.6253 $25.89
71023.............. Chest x-ray and .................. Z3................ 0.8968 $37.13
fluoroscopy.
71030.............. Chest x-ray.............. .................. Z3................ 0.6582 $27.25
71034.............. Chest x-ray and .................. Z2................ 1.3271 $54.94
fluoroscopy.
71035.............. Chest x-ray.............. .................. Z3................ 0.5101 $21.12
71040.............. Contrast x-ray of bronchi CH................ N1................ ........... ...........
71060.............. Contrast x-ray of bronchi CH................ N1................ ........... ...........
71090.............. X-ray & pacemaker CH................ N1................ ........... ...........
insertion.
71100.............. X-ray exam of ribs....... .................. Z3................ 0.4609 $19.08
71101.............. X-ray exam of ribs/chest. .................. Z3................ 0.5514 $22.83
71110.............. X-ray exam of ribs....... .................. Z3................ 0.6007 $24.87
71111.............. X-ray exam of ribs/chest. .................. Z3................ 0.757 $31.34
71120.............. X-ray exam of breastbone. .................. Z3................ 0.4937 $20.44
71130.............. X-ray exam of breastbone. .................. Z3................ 0.5679 $23.51
71250.............. Ct thorax w/o dye........ .................. Z2................ 3.0109 $124.65
71260.............. Ct thorax w/dye.......... .................. Z2................ 4.3564 $180.36
71270.............. Ct thorax w/o & w/dye.... .................. Z2................ 5.1125 $211.66
71275.............. Ct angiography, chest.... .................. Z2................ 5.1641 $213.80
71550.............. Mri chest w/o dye........ .................. Z2................ 5.3933 $223.29
71551.............. Mri chest w/dye.......... .................. Z2................ 6.235 $258.14
71552.............. Mri chest w/o & w/dye.... .................. Z2................ 8.2463 $341.41
72010.............. X-ray exam of spine...... .................. Z2................ 0.6954 $28.79
72020.............. X-ray exam of spine...... .................. Z3................ 0.3456 $14.31
72040.............. X-ray exam of neck spine. .................. Z3................ 0.5348 $22.14
72050.............. X-ray exam of neck spine. .................. Z3................ 0.7652 $31.68
72052.............. X-ray exam of neck spine. .................. Z3................ 0.9874 $40.88
72069.............. X-ray exam of trunk spine .................. Z3................ 0.4773 $19.76
72070.............. X-ray exam of thoracic .................. Z3................ 0.5019 $20.78
spine.
72072.............. X-ray exam of thoracic .................. Z3................ 0.5843 $24.19
spine.
72074.............. X-ray exam of thoracic CH................ Z2................ 0.6954 $28.79
spine.
72080.............. X-ray exam of trunk spine .................. Z3................ 0.5266 $21.80
72090.............. X-ray exam of trunk spine .................. Z3................ 0.6418 $26.57
72100.............. X-ray exam of lower spine .................. Z3................ 0.5761 $23.85
72110.............. X-ray exam of lower spine .................. Z3................ 0.7983 $33.05
72114.............. X-ray exam of lower spine .................. Z3................ 1.078 $44.63
72120.............. X-ray exam of lower spine .................. Z3................ 0.7734 $32.02
72125.............. Ct neck spine w/o dye.... .................. Z2................ 3.0109 $124.65
72126.............. Ct neck spine w/dye...... .................. Z2................ 4.3564 $180.36
72127.............. Ct neck spine w/o & w/dye .................. Z2................ 5.1125 $211.66
72128.............. Ct chest spine w/o dye... .................. Z2................ 3.0109 $124.65
72129.............. Ct chest spine w/dye..... .................. Z2................ 4.3564 $180.36
72130.............. Ct chest spine w/o & w/ .................. Z2................ 5.1125 $211.66
dye.
72131.............. Ct lumbar spine w/o dye.. .................. Z2................ 3.0109 $124.65
72132.............. Ct lumbar spine w/dye.... .................. Z2................ 4.3564 $180.36
72133.............. Ct lumbar spine w/o & w/ .................. Z2................ 5.1125 $211.66
dye.
72141.............. Mri neck spine w/o dye... .................. Z2................ 5.3933 $223.29
72142.............. Mri neck spine w/dye..... .................. Z2................ 6.235 $258.14
72146.............. Mri chest spine w/o dye.. .................. Z2................ 5.3933 $223.29
72147.............. Mri chest spine w/dye.... .................. Z2................ 6.235 $258.14
72148.............. Mri lumbar spine w/o dye. .................. Z2................ 5.3933 $223.29
72149.............. Mri lumbar spine w/dye... .................. Z2................ 6.235 $258.14
72156.............. Mri neck spine w/o & w/ .................. Z2................ 8.2463 $341.41
dye.
72157.............. Mri chest spine w/o & w/ .................. Z2................ 8.2463 $341.41
dye.
72158.............. Mri lumbar spine w/o & w/ .................. Z2................ 8.2463 $341.41
dye.
72170.............. X-ray exam of pelvis..... .................. Z3................ 0.3949 $16.35
72190.............. X-ray exam of pelvis..... .................. Z3................ 0.5925 $24.53
72191.............. Ct angiograph pelv w/o&w/ .................. Z2................ 5.1641 $213.80
dye.
72192.............. Ct pelvis w/o dye........ .................. Z2................ 3.0109 $124.65
72193.............. Ct pelvis w/dye.......... .................. Z2................ 4.3564 $180.36
72194.............. Ct pelvis w/o & w/dye.... .................. Z2................ 5.1125 $211.66
72195.............. Mri pelvis w/o dye....... .................. Z2................ 5.3933 $223.29
72196.............. Mri pelvis w/dye......... .................. Z2................ 6.235 $258.14
72197.............. Mri pelvis w/o & w/dye... .................. Z2................ 8.2463 $341.41
[[Page 67168]]
72200.............. X-ray exam sacroiliac .................. Z3................ 0.4362 $18.06
joints.
72202.............. X-ray exam sacroiliac .................. Z3................ 0.5348 $22.14
joints.
72220.............. X-ray exam of tailbone... .................. Z3................ 0.4526 $18.74
72240.............. Contrast x-ray of neck CH................ N1................ ........... ...........
spine.
72255.............. Contrast x-ray, thorax CH................ N1................ ........... ...........
spine.
72265.............. Contrast x-ray, lower CH................ N1................ ........... ...........
spine.
72270.............. Contrast x-ray, spine.... CH................ N1................ ........... ...........
72275.............. Epidurography............ CH................ N1................ ........... ...........
72285.............. X-ray c/t spine disk..... CH................ N1................ ........... ...........
72291.............. Perq vertebroplasty, CH................ N1................ ........... ...........
fluor.
72292.............. Perq vertebroplasty, ct.. CH................ N1................ ........... ...........
72295.............. X-ray of lower spine disk CH................ N1................ ........... ...........
73000.............. X-ray exam of collar bone .................. Z3................ 0.4196 $17.37
73010.............. X-ray exam of shoulder .................. Z3................ 0.428 $17.72
blade.
73020.............. X-ray exam of shoulder... .................. Z3................ 0.3539 $14.65
73030.............. X-ray exam of shoulder... .................. Z3................ 0.4444 $18.40
73040.............. Contrast x-ray of CH................ N1................ ........... ...........
shoulder.
73050.............. X-ray exam of shoulders.. .................. Z3................ 0.5432 $22.49
73060.............. X-ray exam of humerus.... .................. Z3................ 0.4444 $18.40
73070.............. X-ray exam of elbow...... .................. Z3................ 0.4196 $17.37
73080.............. X-ray exam of elbow...... .................. Z3................ 0.5183 $21.46
73085.............. Contrast x-ray of elbow.. CH................ N1................ ........... ...........
73090.............. X-ray exam of forearm.... .................. Z3................ 0.4196 $17.37
73092.............. X-ray exam of arm, infant .................. Z3................ 0.4196 $17.37
73100.............. X-ray exam of wrist...... .................. Z3................ 0.428 $17.72
73110.............. X-ray exam of wrist...... .................. Z3................ 0.5101 $21.12
73115.............. Contrast x-ray of wrist.. CH................ N1................ ........... ...........
73120.............. X-ray exam of hand....... .................. Z3................ 0.4113 $17.03
73130.............. X-ray exam of hand....... .................. Z3................ 0.4609 $19.08
73140.............. X-ray exam of finger(s).. .................. Z3................ 0.4362 $18.06
73200.............. Ct upper extremity w/o .................. Z2................ 3.0109 $124.65
dye.
73201.............. Ct upper extremity w/dye. .................. Z2................ 4.3564 $180.36
73202.............. Ct uppr extremity w/o&w/ .................. Z2................ 5.1125 $211.66
dye.
73206.............. Ct angio upr extrm w/o&w/ .................. Z2................ 5.1641 $213.80
dye.
73218.............. Mri upper extremity w/o .................. Z2................ 5.3933 $223.29
dye.
73219.............. Mri upper extremity w/dye .................. Z2................ 6.235 $258.14
73220.............. Mri uppr extremity w/o&w/ .................. Z2................ 8.2463 $341.41
dye.
73221.............. Mri joint upr extrem w/o .................. Z2................ 5.3933 $223.29
dye.
73222.............. Mri joint upr extrem w/ .................. Z2................ 6.235 $258.14
dye.
73223.............. Mri joint upr extr w/o&w/ .................. Z2................ 8.2463 $341.41
dye.
73500.............. X-ray exam of hip........ .................. Z3................ 0.3703 $15.33
73510.............. X-ray exam of hip........ .................. Z3................ 0.5266 $21.80
73520.............. X-ray exam of hips....... .................. Z3................ 0.5596 $23.17
73525.............. Contrast x-ray of hip.... CH................ N1................ ........... ...........
73530.............. X-ray exam of hip........ CH................ N1................ ........... ...........
73540.............. X-ray exam of pelvis & .................. Z3................ 0.5348 $22.14
hips.
73542.............. X-ray exam, sacroiliac CH................ N1................ ........... ...........
joint.
73550.............. X-ray exam of thigh...... .................. Z3................ 0.4362 $18.06
73560.............. X-ray exam of knee, 1 or .................. Z3................ 0.428 $17.72
2.
73562.............. X-ray exam of knee, 3.... .................. Z3................ 0.5101 $21.12
73564.............. X-ray exam, knee, 4 or .................. Z3................ 0.5761 $23.85
more.
73565.............. X-ray exam of knees...... .................. Z3................ 0.4444 $18.40
73580.............. Contrast x-ray of knee CH................ N1................ ........... ...........
joint.
73590.............. X-ray exam of lower leg.. .................. Z3................ 0.4113 $17.03
73592.............. X-ray exam of leg, infant .................. Z3................ 0.4196 $17.37
73600.............. X-ray exam of ankle...... .................. Z3................ 0.4113 $17.03
73610.............. X-ray exam of ankle...... .................. Z3................ 0.4691 $19.42
73615.............. Contrast x-ray of ankle.. CH................ N1................ ........... ...........
73620.............. X-ray exam of foot....... .................. Z3................ 0.4031 $16.69
73630.............. X-ray exam of foot....... .................. Z3................ 0.4609 $19.08
73650.............. X-ray exam of heel....... .................. Z3................ 0.3949 $16.35
73660.............. X-ray exam of toe(s)..... .................. Z3................ 0.4196 $17.37
73700.............. Ct lower extremity w/o .................. Z2................ 3.0109 $124.65
dye.
73701.............. Ct lower extremity w/dye. .................. Z2................ 4.3564 $180.36
73702.............. Ct lwr extremity w/o&w/ .................. Z2................ 5.1125 $211.66
dye.
73706.............. Ct angio lwr extr w/o&w/ .................. Z2................ 5.1641 $213.80
dye.
73718.............. Mri lower extremity w/o .................. Z2................ 5.3933 $223.29
dye.
73719.............. Mri lower extremity w/dye .................. Z2................ 6.235 $258.14
[[Page 67169]]
73720.............. Mri lwr extremity w/o&w/ .................. Z2................ 8.2463 $341.41
dye.
73721.............. Mri jnt of lwr extre w/o .................. Z2................ 5.3933 $223.29
dye.
73722.............. Mri joint of lwr extr w/ .................. Z2................ 6.235 $258.14
dye.
73723.............. Mri joint lwr extr w/o&w/ .................. Z2................ 8.2463 $341.41
dye.
74000.............. X-ray exam of abdomen.... .................. Z3................ 0.3785 $15.67
74010.............. X-ray exam of abdomen.... .................. Z3................ 0.5266 $21.80
74020.............. X-ray exam of abdomen.... .................. Z3................ 0.5514 $22.83
74022.............. X-ray exam series, .................. Z3................ 0.6582 $27.25
abdomen.
74150.............. Ct abdomen w/o dye....... .................. Z2................ 3.0109 $124.65
74160.............. Ct abdomen w/dye......... .................. Z2................ 4.3564 $180.36
74170.............. Ct abdomen w/o & w/dye... .................. Z2................ 5.1125 $211.66
74175.............. Ct angio abdom w/o & w/ .................. Z2................ 5.1641 $213.80
dye.
74181.............. Mri abdomen w/o dye...... .................. Z2................ 5.3933 $223.29
74182.............. Mri abdomen w/dye........ .................. Z2................ 6.235 $258.14
74183.............. Mri abdomen w/o & w/dye.. .................. Z2................ 8.2463 $341.41
74190.............. X-ray exam of peritoneum. CH................ N1................ ........... ...........
74210.............. Contrst x-ray exam of .................. Z3................ 1.1604 $48.04
throat.
74220.............. Contrast x-ray, esophagus .................. Z3................ 1.2507 $51.78
74230.............. Cine/vid x-ray, throat/ .................. Z3................ 1.2589 $52.12
esoph.
74235.............. Remove esophagus CH................ N1................ ........... ...........
obstruction.
74240.............. X-ray exam, upper gi CH................ Z2................ 1.3834 $57.27
tract.
74241.............. X-ray exam, upper gi .................. Z2................ 1.3834 $57.27
tract.
74245.............. X-ray exam, upper gi .................. Z2................ 2.2222 $92.00
tract.
74246.............. Contrst x-ray uppr gi .................. Z2................ 1.3834 $57.27
tract.
74247.............. Contrst x-ray uppr gi .................. Z2................ 1.3834 $57.27
tract.
74249.............. Contrst x-ray uppr gi .................. Z2................ 2.2222 $92.00
tract.
74250.............. X-ray exam of small bowel CH................ Z2................ 1.3834 $57.27
74251.............. X-ray exam of small bowel .................. Z2................ 2.2222 $92.00
74260.............. X-ray exam of small bowel .................. Z2................ 1.3834 $57.27
74270.............. Contrast x-ray exam of .................. Z2................ 1.3834 $57.27
colon.
74280.............. Contrast x-ray exam of .................. Z2................ 2.2222 $92.00
colon.
74283.............. Contrast x-ray exam of .................. Z2................ 1.3834 $57.27
colon.
74290.............. Contrast x-ray, .................. Z3................ 0.9053 $37.48
gallbladder.
74291.............. Contrast x-rays, .................. Z3................ 0.7816 $32.36
gallbladder.
74300.............. X-ray bile ducts/pancreas CH................ N1................ ........... ...........
74301.............. X-rays at surgery add-on. CH................ N1................ ........... ...........
74305.............. X-ray bile ducts/pancreas CH................ N1................ ........... ...........
74320.............. Contrast x-ray of bile CH................ N1................ ........... ...........
ducts.
74327.............. X-ray bile stone removal. CH................ N1................ ........... ...........
74328.............. X-ray bile duct endoscopy .................. N1................ ........... ...........
74329.............. X-ray for pancreas .................. N1................ ........... ...........
endoscopy.
74330.............. X-ray bile/panc endoscopy .................. N1................ ........... ...........
74340.............. X-ray guide for gi tube.. CH................ N1................ ........... ...........
74350.............. X-ray guide, stomach tube CH................ D5................ ........... ...........
74355.............. X-ray guide, intestinal CH................ N1................ ........... ...........
tube.
74360.............. X-ray guide, gi dilation. CH................ N1................ ........... ...........
74363.............. X-ray, bile duct dilation CH................ N1................ ........... ...........
74400.............. Contrst x-ray, urinary .................. Z3................ 1.6869 $69.84
tract.
74410.............. Contrst x-ray, urinary .................. Z3................ 1.835 $75.97
tract.
74415.............. Contrst x-ray, urinary .................. Z3................ 2.1478 $88.92
tract.
74420.............. Contrst x-ray, urinary .................. Z2................ 2.6121 $108.14
tract.
74425.............. Contrst x-ray, urinary CH................ N1................ ........... ...........
tract.
74430.............. Contrast x-ray, bladder.. CH................ N1................ ........... ...........
74440.............. X-ray, male genital tract CH................ N1................ ........... ...........
74445.............. X-ray exam of penis...... CH................ N1................ ........... ...........
74450.............. X-ray, urethra/bladder... CH................ N1................ ........... ...........
74455.............. X-ray, urethra/bladder... CH................ N1................ ........... ...........
74470.............. X-ray exam of kidney CH................ N1................ ........... ...........
lesion.
74475.............. X-ray control, cath CH................ N1................ ........... ...........
insert.
74480.............. X-ray control, cath CH................ N1................ ........... ...........
insert.
74485.............. X-ray guide, gu dilation. CH................ N1................ ........... ...........
74710.............. X-ray measurement of .................. Z3................ 0.65 $26.91
pelvis.
74740.............. X-ray, female genital CH................ N1................ ........... ...........
tract.
74742.............. X-ray, fallopian tube.... CH................ N1................ ........... ...........
74775.............. X-ray exam of perineum... .................. Z2................ 2.6121 $108.14
75552.............. Heart mri for morph w/o CH................ D5................ ........... ...........
dye.
75553.............. Heart mri for morph w/dye CH................ D5................ ........... ...........
75554.............. Cardiac MRI/function..... CH................ D5................ ........... ...........
[[Page 67170]]
75555.............. Cardiac MRI/limited study CH................ D5................ ........... ...........
75557.............. Cardiac mri for morph.... NI................ Z2................ 5.3933 $223.29
75559.............. Cardiac mri w/stress img. NI................ Z2................ 5.3933 $223.29
75561.............. Cardiac mri for morph w/ NI................ Z2................ 8.2463 $341.41
dye.
75563.............. Card mri w/stress img & NI................ Z2................ 8.2463 $341.41
dye.
75600.............. Contrast x-ray exam of CH................ N1................ ........... ...........
aorta.
75605.............. Contrast x-ray exam of CH................ N1................ ........... ...........
aorta.
75625.............. Contrast x-ray exam of CH................ N1................ ........... ...........
aorta.
75630.............. X-ray aorta, leg arteries CH................ N1................ ........... ...........
75635.............. Ct angio abdominal CH................ N1................ ........... ...........
arteries.
75650.............. Artery x-rays, head & CH................ N1................ ........... ...........
neck.
75658.............. Artery x-rays, arm....... CH................ N1................ ........... ...........
75660.............. Artery x-rays, head & CH................ N1................ ........... ...........
neck.
75662.............. Artery x-rays, head & CH................ N1................ ........... ...........
neck.
75665.............. Artery x-rays, head & CH................ N1................ ........... ...........
neck.
75671.............. Artery x-rays, head & CH................ N1................ ........... ...........
neck.
75676.............. Artery x-rays, neck...... CH................ N1................ ........... ...........
75680.............. Artery x-rays, neck...... CH................ N1................ ........... ...........
75685.............. Artery x-rays, spine..... CH................ N1................ ........... ...........
75705.............. Artery x-rays, spine..... CH................ N1................ ........... ...........
75710.............. Artery x-rays, arm/leg... CH................ N1................ ........... ...........
75716.............. Artery x-rays, arms/legs. CH................ N1................ ........... ...........
75722.............. Artery x-rays, kidney.... CH................ N1................ ........... ...........
75724.............. Artery x-rays, kidneys... CH................ N1................ ........... ...........
75726.............. Artery x-rays, abdomen... CH................ N1................ ........... ...........
75731.............. Artery x-rays, adrenal CH................ N1................ ........... ...........
gland.
75733.............. Artery x-rays, adrenals.. CH................ N1................ ........... ...........
75736.............. Artery x-rays, pelvis.... CH................ N1................ ........... ...........
75741.............. Artery x-rays, lung...... CH................ N1................ ........... ...........
75743.............. Artery x-rays, lungs..... CH................ N1................ ........... ...........
75746.............. Artery x-rays, lung...... CH................ N1................ ........... ...........
75756.............. Artery x-rays, chest..... CH................ N1................ ........... ...........
75774.............. Artery x-ray, each vessel CH................ N1................ ........... ...........
75790.............. Visualize a-v shunt...... CH................ N1................ ........... ...........
75801.............. Lymph vessel x-ray, arm/ CH................ N1................ ........... ...........
leg.
75803.............. Lymph vessel x-ray,arms/ CH................ N1................ ........... ...........
legs.
75805.............. Lymph vessel x-ray, trunk CH................ N1................ ........... ...........
75807.............. Lymph vessel x-ray, trunk CH................ N1................ ........... ...........
75809.............. Nonvascular shunt, x-ray. CH................ N1................ ........... ...........
75810.............. Vein x-ray, spleen/liver. CH................ N1................ ........... ...........
75820.............. Vein x-ray, arm/leg...... CH................ N1................ ........... ...........
75822.............. Vein x-ray, arms/legs.... CH................ N1................ ........... ...........
75825.............. Vein x-ray, trunk........ CH................ N1................ ........... ...........
75827.............. Vein x-ray, chest........ CH................ N1................ ........... ...........
75831.............. Vein x-ray, kidney....... CH................ N1................ ........... ...........
75833.............. Vein x-ray, kidneys...... CH................ N1................ ........... ...........
75840.............. Vein x-ray, adrenal gland CH................ N1................ ........... ...........
75842.............. Vein x-ray, adrenal CH................ N1................ ........... ...........
glands.
75860.............. Vein x-ray, neck......... CH................ N1................ ........... ...........
75870.............. Vein x-ray, skull........ CH................ N1................ ........... ...........
75872.............. Vein x-ray, skull........ CH................ N1................ ........... ...........
75880.............. Vein x-ray, eye socket... CH................ N1................ ........... ...........
75885.............. Vein x-ray, liver........ CH................ N1................ ........... ...........
75887.............. Vein x-ray, liver........ CH................ N1................ ........... ...........
75889.............. Vein x-ray, liver........ CH................ N1................ ........... ...........
75891.............. Vein x-ray, liver........ CH................ N1................ ........... ...........
75893.............. Venous sampling by .................. N1................ ........... ...........
catheter.
75894.............. X-rays, transcath therapy CH................ N1................ ........... ...........
75896.............. X-rays, transcath therapy CH................ N1................ ........... ...........
75898.............. Follow-up angiography.... CH................ N1................ ........... ...........
75901.............. Remove cva device CH................ N1................ ........... ...........
obstruct.
75902.............. Remove cva lumen obstruct CH................ N1................ ........... ...........
75940.............. X-ray placement, vein CH................ N1................ ........... ...........
filter.
75945.............. Intravascular us......... CH................ N1................ ........... ...........
75946.............. Intravascular us add-on.. CH................ N1................ ........... ...........
75960.............. Transcath iv stent rs&i.. CH................ N1................ ........... ...........
75961.............. Retrieval, broken CH................ N1................ ........... ...........
catheter.
75962.............. Repair arterial blockage. CH................ N1................ ........... ...........
[[Page 67171]]
75964.............. Repair artery blockage, CH................ N1................ ........... ...........
each.
75966.............. Repair arterial blockage. CH................ N1................ ........... ...........
75968.............. Repair artery blockage, CH................ N1................ ........... ...........
each.
75970.............. Vascular biopsy.......... CH................ N1................ ........... ...........
75978.............. Repair venous blockage... CH................ N1................ ........... ...........
75980.............. Contrast xray exam bile CH................ N1................ ........... ...........
duct.
75982.............. Contrast xray exam bile CH................ N1................ ........... ...........
duct.
75984.............. Xray control catheter CH................ N1................ ........... ...........
change.
75989.............. Abscess drainage under x- .................. N1................ ........... ...........
ray.
75992.............. Atherectomy, x-ray exam.. CH................ N1................ ........... ...........
75993.............. Atherectomy, x-ray exam.. CH................ N1................ ........... ...........
75994.............. Atherectomy, x-ray exam.. CH................ N1................ ........... ...........
75995.............. Atherectomy, x-ray exam.. CH................ N1................ ........... ...........
75996.............. Atherectomy, x-ray exam.. CH................ N1................ ........... ...........
76000.............. Fluoroscope examination.. CH................ N1................ ........... ...........
76001.............. Fluoroscope exam, .................. N1................ ........... ...........
extensive.
76010.............. X-ray, nose to rectum.... .................. Z3................ 0.4113 $17.03
76080.............. X-ray exam of fistula.... CH................ N1................ ........... ...........
76098.............. X-ray exam, breast .................. Z3................ 0.2797 $11.58
specimen.
76100.............. X-ray exam of body .................. Z2................ 1.157 $47.90
section.
76101.............. Complex body section x- CH................ Z3................ 2.7485 $113.79
ray.
76102.............. Complex body section x- .................. Z2................ 2.6838 $111.11
rays.
76120.............. Cine/video x-rays........ .................. Z3................ 1.1437 $47.35
76125.............. Cine/video x-rays add-on. CH................ N1................ ........... ...........
76150.............. X-ray exam, dry process.. .................. Z3................ 0.4526 $18.74
76350.............. Special x-ray contrast .................. N1................ ........... ...........
study.
76376.............. 3d render w/o postprocess CH................ N1................ ........... ...........
76377.............. 3d rendering w/ CH................ N1................ ........... ...........
postprocess.
76380.............. Cat scan follow-up study. .................. Z2................ 1.5839 $65.58
76496.............. Fluoroscopic procedure... .................. Z2................ 1.3271 $54.94
76497.............. Ct procedure............. .................. Z2................ 1.5839 $65.58
76498.............. Mri procedure............ .................. Z2................ 4.883 $202.16
76499.............. Radiographic procedure... .................. Z2................ 0.6954 $28.79
76506.............. Echo exam of head........ .................. Z2................ 0.957 $39.62
76510.............. Ophth us, b & quant a.... CH................ Z3................ 1.5963 $66.09
76511.............. Ophth us, quant a only... .................. Z3................ 1.2507 $51.78
76512.............. Ophth us, b w/non-quant a .................. Z3................ 1.0862 $44.97
76513.............. Echo exam of eye, water .................. Z3................ 1.1521 $47.70
bath.
76514.............. Echo exam of eye, .................. Z3................ 0.0659 $2.73
thickness.
76516.............. Echo exam of eye......... .................. Z3................ 0.8968 $37.13
76519.............. Echo exam of eye......... .................. Z3................ 0.9874 $40.88
76529.............. Echo exam of eye......... .................. Z3................ 0.8558 $35.43
76536.............. Us exam of head and neck. CH................ Z2................ 1.5094 $62.49
76604.............. Us exam, chest........... .................. Z2................ 0.957 $39.62
76645.............. Us exam, breast(s)....... .................. Z2................ 0.957 $39.62
76700.............. Us exam, abdom, complete. .................. Z2................ 1.5094 $62.49
76705.............. Echo exam of abdomen..... .................. Z3................ 1.4647 $60.64
76770.............. Us exam abdo back wall, .................. Z2................ 1.5094 $62.49
comp.
76775.............. Us exam abdo back wall, .................. Z3................ 1.4893 $61.66
lim.
76776.............. Us exam k transpl w/ .................. Z2................ 1.5094 $62.49
doppler.
76800.............. Us exam, spinal canal.... .................. Z3................ 1.4154 $58.60
76801.............. Ob us < 14 wks, single .................. Z2................ 1.5094 $62.49
fetus.
76802.............. Ob us < 14 wks, add'l .................. Z3................ 0.7241 $29.98
fetus.
76805.............. Ob us >/= 14 wks, sngl .................. Z2................ 1.5094 $62.49
fetus.
76810.............. Ob us >/= 14 wks, addl .................. Z3................ 0.9874 $40.88
fetus.
76811.............. Ob us, detailed, sngl CH................ Z2................ 2.3792 $98.50
fetus.
76812.............. Ob us, detailed, addl .................. Z2................ 0.957 $39.62
fetus.
76813.............. Ob us nuchal meas, 1 gest .................. Z3................ 1.4893 $61.66
76814.............. Ob us nuchal meas, add-on .................. Z3................ 0.7077 $29.30
76815.............. Ob us, limited, fetus(s). .................. Z2................ 0.957 $39.62
76816.............. Ob us, follow-up, per .................. Z2................ 0.957 $39.62
fetus.
76817.............. Transvaginal us, .................. Z2................ 0.957 $39.62
obstetric.
76818.............. Fetal biophys profile w/ .................. Z3................ 1.4483 $59.96
nst.
76819.............. Fetal biophys profil w/o .................. Z3................ 1.2343 $51.10
nst.
76820.............. Umbilical artery echo.... .................. Z3................ 0.8311 $34.41
76821.............. Middle cerebral artery .................. Z3................ 1.3413 $55.53
echo.
76825.............. Echo exam of fetal heart. .................. Z2................ 1.5094 $62.49
76826.............. Echo exam of fetal heart. CH................ Z2................ 0.957 $39.62
[[Page 67172]]
76827.............. Echo exam of fetal heart. CH................ Z2................ 0.957 $39.62
76828.............. Echo exam of fetal heart. .................. Z3................ 0.65 $26.91
76830.............. Transvaginal us, non-ob.. .................. Z2................ 1.5094 $62.49
76831.............. Echo exam, uterus........ .................. Z3................ 1.6623 $68.82
76856.............. Us exam, pelvic, complete .................. Z2................ 1.5094 $62.49
76857.............. Us exam, pelvic, limited. .................. Z2................ 0.957 $39.62
76870.............. Us exam, scrotum......... .................. Z2................ 1.5094 $62.49
76872.............. Us, transrectal.......... .................. Z2................ 1.5094 $62.49
76873.............. Echograp trans r, pros .................. Z2................ 1.5094 $62.49
study.
76880.............. Us exam, extremity....... .................. Z2................ 1.5094 $62.49
76885.............. Us exam infant hips, .................. Z2................ 0.957 $39.62
dynamic.
76886.............. Us exam infant hips, .................. Z2................ 0.957 $39.62
static.
76930.............. Echo guide, CH................ N1................ ........... ...........
cardiocentesis.
76932.............. Echo guide for heart CH................ N1................ ........... ...........
biopsy.
76936.............. Echo guide for artery CH................ N1................ ........... ...........
repair.
76937.............. Us guide, vascular access .................. N1................ ........... ...........
76940.............. Us guide, tissue ablation CH................ N1................ ........... ...........
76941.............. Echo guide for CH................ N1................ ........... ...........
transfusion.
76942.............. Echo guide for biopsy.... CH................ N1................ ........... ...........
76945.............. Echo guide, villus CH................ N1................ ........... ...........
sampling.
76946.............. Echo guide for CH................ N1................ ........... ...........
amniocentesis.
76948.............. Echo guide, ova CH................ N1................ ........... ...........
aspiration.
76950.............. Echo guidance CH................ N1................ ........... ...........
radiotherapy.
76965.............. Echo guidance CH................ N1................ ........... ...........
radiotherapy.
76970.............. Ultrasound exam follow-up .................. Z2................ 0.957 $39.62
76975.............. Gi endoscopic ultrasound. CH................ N1................ ........... ...........
76977.............. Us bone density measure.. .................. Z3................ 0.3785 $15.67
76998.............. Us guide, intraop........ CH................ N1................ ........... ...........
76999.............. Echo examination .................. Z2................ 0.957 $39.62
procedure.
77001.............. Fluoroguide for vein .................. N1................ ........... ...........
device.
77002.............. Needle localization by .................. N1................ ........... ...........
xray.
77003.............. Fluoroguide for spine .................. N1................ ........... ...........
inject.
77011.............. Ct scan for localization. CH................ N1................ ........... ...........
77012.............. Ct scan for needle biopsy CH................ N1................ ........... ...........
77013.............. Ct guide for tissue CH................ N1................ ........... ...........
ablation.
77014.............. Ct scan for therapy guide CH................ N1................ ........... ...........
77021.............. Mr guidance for needle CH................ N1................ ........... ...........
place.
77022.............. Mri for tissue ablation.. CH................ N1................ ........... ...........
77031.............. Stereotact guide for brst CH................ N1................ ........... ...........
bx.
77032.............. Guidance for needle, CH................ N1................ ........... ...........
breast.
77053.............. X-ray of mammary duct.... CH................ N1................ ........... ...........
77054.............. X-ray of mammary ducts... CH................ N1................ ........... ...........
77071.............. X-ray stress view........ .................. Z3................ 0.3867 $16.01
77072.............. X-rays for bone age...... .................. Z3................ 0.2961 $12.26
77073.............. X-rays, bone length .................. Z3................ 0.5514 $22.83
studies.
77074.............. X-rays, bone survey, .................. Z3................ 0.9381 $38.84
limited.
77075.............. X-rays, bone survey .................. Z2................ 1.157 $47.90
complete.
77076.............. X-rays, bone survey, .................. Z2................ 0.6954 $28.79
infant.
77077.............. Joint survey, single view CH................ Z2................ 0.6831 $28.28
77078.............. Ct bone density, axial... .................. Z2................ 1.1384 $47.13
77079.............. Ct bone density, CH................ Z2................ 1.5224 $63.03
peripheral.
77080.............. Dxa bone density, axial.. .................. Z2................ 1.1384 $47.13
77081.............. Dxa bone density/ .................. Z2................ 0.4773 $19.76
peripheral.
77082.............. Dxa bone density, vert fx .................. Z3................ 0.5019 $20.78
77083.............. Radiographic .................. Z3................ 0.4362 $18.06
absorptiometry.
77084.............. Magnetic image, bone .................. Z2................ 4.883 $202.16
marrow.
77280.............. Set radiation therapy .................. Z2................ 1.5576 $64.49
field.
77285.............. Set radiation therapy .................. Z2................ 3.9276 $162.61
field.
77290.............. Set radiation therapy .................. Z2................ 3.9276 $162.61
field.
77295.............. Set radiation therapy CH................ Z2................ 13.5621 $561.48
field.
77299.............. Radiation therapy .................. Z2................ 1.5576 $64.49
planning.
77300.............. Radiation therapy dose .................. Z3................ 0.9546 $39.52
plan.
77301.............. Radiotherapy dose plan, .................. Z2................ 13.5621 $561.48
imrt.
77305.............. Teletx isodose plan .................. Z3................ 1.0451 $43.27
simple.
77310.............. Teletx isodose plan .................. Z3................ 1.3331 $55.19
intermed.
77315.............. Teletx isodose plan .................. Z3................ 1.7444 $72.22
complex.
77321.............. Special teletx port plan. .................. Z3................ 2.156 $89.26
77326.............. Brachytx isodose calc .................. Z2................ 1.5576 $64.49
simp.
[[Page 67173]]
77327.............. Brachytx isodose calc .................. Z3................ 2.9212 $120.94
interm.
77328.............. Brachytx isodose plan .................. Z3................ 3.9168 $162.16
compl.
77331.............. Special radiation .................. Z3................ 0.4196 $17.37
dosimetry.
77332.............. Radiation treatment .................. Z3................ 1.1108 $45.99
aid(s).
77333.............. Radiation treatment .................. Z3................ 0.8804 $36.45
aid(s).
77334.............. Radiation treatment .................. Z3................ 2.2876 $94.71
aid(s).
77336.............. Radiation physics consult .................. Z2................ 1.5576 $64.49
77370.............. Radiation physics consult .................. Z2................ 1.5576 $64.49
77371.............. Srs, multisource......... .................. Z3................ 24.7441 $1,024.43
77399.............. External radiation .................. Z2................ 1.5576 $64.49
dosimetry.
77401.............. Radiation treatment .................. Z3................ 0.9217 $38.16
delivery.
77402.............. Radiation treatment .................. Z2................ 1.4229 $58.91
delivery.
77403.............. Radiation treatment .................. Z2................ 1.4229 $58.91
delivery.
77404.............. Radiation treatment .................. Z2................ 1.4229 $58.91
delivery.
77406.............. Radiation treatment .................. Z2................ 1.4229 $58.91
delivery.
77407.............. Radiation treatment .................. Z2................ 1.4229 $58.91
delivery.
77408.............. Radiation treatment .................. Z2................ 1.4229 $58.91
delivery.
77409.............. Radiation treatment .................. Z2................ 1.4229 $58.91
delivery.
77411.............. Radiation treatment .................. Z2................ 2.2167 $91.77
delivery.
77412.............. Radiation treatment .................. Z2................ 2.2167 $91.77
delivery.
77413.............. Radiation treatment .................. Z2................ 2.2167 $91.77
delivery.
77414.............. Radiation treatment .................. Z2................ 2.2167 $91.77
delivery.
77416.............. Radiation treatment .................. Z2................ 2.2167 $91.77
delivery.
77417.............. Radiology port film(s)... CH................ N1................ ........... ...........
77418.............. Radiation tx delivery, .................. Z2................ 5.4582 $225.97
imrt.
77421.............. Stereoscopic x-ray CH................ N1................ ........... ...........
guidance.
77422.............. Neutron beam tx, simple.. .................. Z2................ 2.2167 $91.77
77423.............. Neutron beam tx, complex. .................. Z2................ 2.2167 $91.77
77435.............. Sbrt management.......... .................. N1................ ........... ...........
77470.............. Special radiation .................. Z3................ 5.0936 $210.88
treatment.
77520.............. Proton trmt, simple w/o .................. Z2................ 12.8205 $530.78
comp.
77522.............. Proton trmt, simple w/ .................. Z2................ 12.8205 $530.78
comp.
77523.............. Proton trmt, intermediate .................. Z2................ 15.3404 $635.11
77525.............. Proton treatment, complex .................. Z2................ 15.3404 $635.11
77600.............. Hyperthermia treatment... CH................ Z3................ 5.2583 $217.70
77605.............. Hyperthermia treatment... .................. Z2................ 5.7996 $240.11
77610.............. Hyperthermia treatment... .................. Z2................ 5.7996 $240.11
77615.............. Hyperthermia treatment... .................. Z2................ 5.7996 $240.11
77620.............. Hyperthermia treatment... CH................ Z3................ 5.4064 $223.83
77750.............. Infuse radioactive .................. Z3................ 1.7529 $72.57
materials.
77761.............. Apply intrcav radiat .................. Z3................ 3.127 $129.46
simple.
77762.............. Apply intrcav radiat .................. Z3................ 3.8511 $159.44
interm.
77763.............. Apply intrcav radiat .................. Z3................ 4.9373 $204.41
compl.
77776.............. Apply interstit radiat .................. Z3................ 3.275 $135.59
simpl.
77777.............. Apply interstit radiat .................. Z3................ 3.991 $165.23
inter.
77778.............. Apply interstit radiat .................. Z3................ 5.2417 $217.01
compl.
77781.............. High intensity .................. Z3................ 9.9981 $413.93
brachytherapy.
77782.............. High intensity .................. Z2................ 11.6779 $483.48
brachytherapy.
77783.............. High intensity .................. Z2................ 11.6779 $483.48
brachytherapy.
77784.............. High intensity .................. Z2................ 11.6779 $483.48
brachytherapy.
77789.............. Apply surface radiation.. .................. Z3................ 0.8558 $35.43
77790.............. Radiation handling....... .................. N1................ ........... ...........
77799.............. Radium/radioisotope .................. Z2................ 8.514 $352.49
therapy.
78000.............. Thyroid, single uptake... .................. Z3................ 1.1355 $47.01
78001.............. Thyroid, multiple uptakes .................. Z3................ 1.4483 $59.96
78003.............. Thyroid suppress/stimul.. .................. Z3................ 1.1437 $47.35
78006.............. Thyroid imaging with CH................ Z3................ 3.4726 $143.77
uptake.
78007.............. Thyroid image, mult .................. Z3................ 2.2466 $93.01
uptakes.
78010.............. Thyroid imaging.......... CH................ Z2................ 2.0471 $84.75
78011.............. Thyroid imaging with flow .................. Z2................ 2.0471 $84.75
78015.............. Thyroid met imaging...... .................. Z3................ 3.1598 $130.82
78016.............. Thyroid met imaging/ CH................ Z3................ 4.8221 $199.64
studies.
78018.............. Thyroid met imaging, body .................. Z2................ 5.0681 $209.82
78020.............. Thyroid met uptake....... CH................ N1................ ........... ...........
78070.............. Parathyroid nuclear CH................ Z3................ 3.0692 $127.07
imaging.
78075.............. Adrenal nuclear imaging.. CH................ Z3................ 6.9039 $285.83
78099.............. Endocrine nuclear .................. Z2................ 2.0471 $84.75
procedure.
78102.............. Bone marrow imaging, ltd. .................. Z3................ 2.477 $102.55
[[Page 67174]]
78103.............. Bone marrow imaging, mult .................. Z3................ 3.4313 $142.06
78104.............. Bone marrow imaging, body .................. Z2................ 3.9293 $162.68
78110.............. Plasma volume, single.... .................. Z3................ 1.2343 $51.10
78111.............. Plasma volume, multiple.. .................. Z3................ 1.9091 $79.04
78120.............. Red cell mass, single.... .................. Z3................ 1.5471 $64.05
78121.............. Red cell mass, multiple.. .................. Z3................ 2.0572 $85.17
78122.............. Blood volume............. .................. Z3................ 2.7567 $114.13
78130.............. Red cell survival study.. .................. Z3................ 2.5263 $104.59
78135.............. Red cell survival CH................ Z3................ 5.4803 $226.89
kinetics.
78140.............. Red cell sequestration... .................. Z3................ 2.7321 $113.11
78185.............. Spleen imaging........... .................. Z3................ 3.0528 $126.39
78190.............. Platelet survival, .................. Z2................ 2.9022 $120.15
kinetics.
78191.............. Platelet survival........ .................. Z2................ 2.9022 $120.15
78195.............. Lymph system imaging..... .................. Z2................ 3.9293 $162.68
78199.............. Blood/lymph nuclear exam. .................. Z2................ 3.9293 $162.68
78201.............. Liver imaging............ .................. Z3................ 2.806 $116.17
78202.............. Liver imaging with flow.. .................. Z3................ 3.3161 $137.29
78205.............. Liver imaging (3d)....... .................. Z3................ 4.4929 $186.01
78206.............. Liver image (3d) with .................. Z2................ 4.4603 $184.66
flow.
78215.............. Liver and spleen imaging. .................. Z3................ 3.1188 $129.12
78216.............. Liver & spleen image/flow .................. Z3................ 2.5263 $104.59
78220.............. Liver function study..... .................. Z3................ 2.7238 $112.77
78223.............. Hepatobiliary imaging.... .................. Z2................ 4.4603 $184.66
78230.............. Salivary gland imaging... .................. Z3................ 2.5509 $105.61
78231.............. Serial salivary imaging.. .................. Z3................ 2.3864 $98.80
78232.............. Salivary gland function .................. Z3................ 2.5345 $104.93
exam.
78258.............. Esophageal motility study .................. Z3................ 3.341 $138.32
78261.............. Gastric mucosa imaging... .................. Z2................ 3.7911 $156.96
78262.............. Gastroesophageal reflux .................. Z2................ 3.7911 $156.96
exam.
78264.............. Gastric emptying study... .................. Z2................ 3.7911 $156.96
78270.............. Vit b-12 absorption exam. .................. Z3................ 1.4072 $58.26
78271.............. Vit b-12 absrp exam, int .................. Z3................ 1.4236 $58.94
fac.
78272.............. Vit b-12 absorp, combined .................. Z3................ 1.7693 $73.25
78278.............. Acute gi blood loss .................. Z2................ 3.7911 $156.96
imaging.
78282.............. Gi protein loss exam..... .................. Z2................ 3.7911 $156.96
78290.............. Meckels divert exam...... .................. Z2................ 3.7911 $156.96
78291.............. Leveen/shunt patency exam .................. Z3................ 3.6617 $151.60
78299.............. Gi nuclear procedure..... .................. Z2................ 3.7911 $156.96
78300.............. Bone imaging, limited .................. Z3................ 2.6743 $110.72
area.
78305.............. Bone imaging, multiple .................. Z3................ 3.6371 $150.58
areas.
78306.............. Bone imaging, whole body. CH................ Z2................ 3.8039 $157.49
78315.............. Bone imaging, 3 phase.... .................. Z2................ 3.8039 $157.49
78320.............. Bone imaging (3d)........ .................. Z2................ 3.8039 $157.49
78399.............. Musculoskeletal nuclear .................. Z2................ 3.8039 $157.49
exam.
78414.............. Non-imaging heart .................. Z2................ 4.862 $201.29
function.
78428.............. Cardiac shunt imaging.... .................. Z3................ 2.9458 $121.96
78445.............. Vascular flow imaging.... CH................ Z3................ 2.5427 $105.27
78456.............. Acute venous thrombus .................. Z2................ 3.1433 $130.14
image.
78457.............. Venous thrombosis imaging CH................ Z3................ 2.9048 $120.26
78458.............. Ven thrombosis images, .................. Z2................ 3.1433 $130.14
bilat.
78459.............. Heart muscle imaging .................. Z2................ 21.9955 $910.64
(pet).
78460.............. Heart muscle blood, .................. Z3................ 2.7567 $114.13
single.
78461.............. Heart muscle blood, .................. Z3................ 3.4231 $141.72
multiple.
78464.............. Heart image (3d), single. CH................ Z3................ 5.11 $211.56
78465.............. Heart image (3d), CH................ Z3................ 9.2657 $383.61
multiple.
78466.............. Heart infarct image...... .................. Z3................ 2.8391 $117.54
78468.............. Heart infarct image (ef). .................. Z3................ 3.7523 $155.35
78469.............. Heart infarct image (3d). CH................ Z3................ 4.5506 $188.40
78472.............. Gated heart, planar, CH................ Z3................ 4.5753 $189.42
single.
78473.............. Gated heart, multiple.... .................. Z2................ 4.862 $201.29
78478.............. Heart wall motion add-on. CH................ N1................ ........... ...........
78480.............. Heart function add-on.... CH................ N1................ ........... ...........
78481.............. Heart first pass, single. .................. Z3................ 4.032 $166.93
78483.............. Heart first pass, .................. Z2................ 4.862 $201.29
multiple.
78491.............. Heart image (pet), single .................. Z2................ 21.9955 $910.64
78492.............. Heart image (pet), .................. Z2................ 21.9955 $910.64
multiple.
78494.............. Heart image, spect....... .................. Z2................ 4.862 $201.29
78496.............. Heart first pass add-on.. CH................ N1................ ........... ...........
[[Page 67175]]
78499.............. Cardiovascular nuclear .................. Z2................ 4.862 $201.29
exam.
78580.............. Lung perfusion imaging... CH................ Z3................ 3.4149 $141.38
78584.............. Lung v/q image single .................. Z3................ 2.4111 $99.82
breath.
78585.............. Lung v/q imaging......... .................. Z2................ 4.9509 $204.97
78586.............. Aerosol lung image, .................. Z3................ 2.7238 $112.77
single.
78587.............. Aerosol lung image, .................. Z3................ 3.3161 $137.29
multiple.
78588.............. Perfusion lung image..... .................. Z3................ 4.7233 $195.55
78591.............. Vent image, 1 breath, 1 .................. Z3................ 2.8306 $117.19
proj.
78593.............. Vent image, 1 proj, gas.. .................. Z3................ 3.3328 $137.98
78594.............. Vent image, mult proj, .................. Z2................ 3.3954 $140.57
gas.
78596.............. Lung differential .................. Z2................ 4.9509 $204.97
function.
78599.............. Respiratory nuclear exam. .................. Z2................ 3.3954 $140.57
78600.............. Brain image < 4 views.... .................. Z3................ 2.9294 $121.28
78601.............. Brain image w/flow < 4 CH................ Z2................ 3.2295 $133.70
views.
78605.............. Brain image 4+ views..... .................. Z3................ 3.3161 $137.29
78606.............. Brain image w/flow 4 + CH................ Z3................ 5.0115 $207.48
views.
78607.............. Brain imaging (3d)....... CH................ Z3................ 6.0728 $251.42
78608.............. Brain imaging (pet)...... .................. Z2................ 16.6001 $687.26
78610.............. Brain flow imaging only.. .................. Z3................ 3.3738 $139.68
78615.............. Cerebral vascular flow CH................ D5................ ........... ...........
image.
78630.............. Cerebrospinal fluid scan. CH................ Z3................ 5.5298 $228.94
78635.............. Csf ventriculography..... CH................ Z3................ 4.5753 $189.42
78645.............. Csf shunt evaluation..... .................. Z2................ 3.2295 $133.70
78647.............. Cerebrospinal fluid scan. CH................ Z3................ 5.8177 $240.86
78650.............. Csf leakage imaging...... CH................ Z3................ 5.3405 $221.10
78660.............. Nuclear exam of tear flow .................. Z3................ 2.5509 $105.61
78699.............. Nervous system nuclear .................. Z2................ 3.2295 $133.70
exam.
78700.............. Kidney imaging, morphol.. .................. Z3................ 2.9953 $124.01
78701.............. Kidney imaging with flow. .................. Z3................ 3.6043 $149.22
78707.............. K flow/funct image w/o CH................ Z3................ 3.9581 $163.87
drug.
78708.............. K flow/funct image w/drug .................. Z3................ 3.0941 $128.10
78709.............. K flow/funct image, .................. Z2................ 5.0824 $210.42
multiple.
78710.............. Kidney imaging (3d)...... CH................ Z3................ 4.5093 $186.69
78725.............. Kidney function study.... CH................ Z3................ 1.6541 $68.48
78730.............. Urinary bladder retention CH................ Z3................ 1.3908 $57.58
78740.............. Ureteral reflux study.... .................. Z3................ 3.1188 $129.12
78761.............. Testicular imaging w/flow .................. Z3................ 3.2915 $136.27
78799.............. Genitourinary nuclear .................. Z2................ 5.0824 $210.42
exam.
78800.............. Tumor imaging, limited .................. Z3................ 3.0941 $128.10
area.
78801.............. Tumor imaging, mult areas .................. Z3................ 4.1144 $170.34
78802.............. Tumor imaging, whole body CH................ Z3................ 5.5052 $227.92
78803.............. Tumor imaging (3d)....... CH................ Z3................ 6.0564 $250.74
78804.............. Tumor imaging, whole body CH................ Z3................ 10.5 $434.71
78805.............. Abscess imaging, ltd area .................. Z3................ 3.0364 $125.71
78806.............. Abscess imaging, whole CH................ Z3................ 5.9576 $246.65
body.
78807.............. Nuclear localization/ CH................ Z3................ 6.0482 $250.40
abscess.
78811.............. Pet image, ltd area...... .................. Z2................ 16.6001 $687.26
78812.............. Pet image, skull-thigh... .................. Z2................ 16.6001 $687.26
78813.............. Pet image, full body..... .................. Z2................ 16.6001 $687.26
78814.............. Pet image w/ct, lmtd..... .................. Z2................ 16.6001 $687.26
78815.............. Pet image w/ct, skull- .................. Z2................ 16.6001 $687.26
thigh.
78816.............. Pet image w/ct, full body .................. Z2................ 16.6001 $687.26
78890.............. Nuclear medicine data .................. N1................ ........... ...........
proc.
78891.............. Nuclear med data proc.... .................. N1................ ........... ...........
78999.............. Nuclear diagnostic exam.. .................. Z2................ 1.819 $75.31
79005.............. Nuclear rx, oral admin... .................. Z3................ 1.5963 $66.09
79101.............. Nuclear rx, iv admin..... .................. Z3................ 1.6623 $68.82
79200.............. Nuclear rx, intracav .................. Z3................ 1.728 $71.54
admin.
79300.............. Nuclr rx, interstit .................. Z2................ 3.302 $136.71
colloid.
79403.............. Hematopoietic nuclear tx. .................. Z3................ 2.6497 $109.70
79440.............. Nuclear rx, intra- .................. Z3................ 1.5553 $64.39
articular.
79445.............. Nuclear rx, intra- .................. Z2................ 3.302 $136.71
arterial.
79999.............. Nuclear medicine therapy. .................. Z2................ 3.302 $136.71
90296.............. Diphtheria antitoxin..... CH................ N1................ ........... ...........
90371.............. Hep b ig, im............. .................. K2................ ........... $122.02
90375.............. Rabies ig, im/sc......... .................. K2................ ........... $68.22
90376.............. Rabies ig, heat treated.. .................. K2................ ........... $71.69
90385.............. Rh ig, minidose, im...... CH................ N1................ ........... ...........
[[Page 67176]]
90393.............. Vaccina ig, im........... CH................ N1................ ........... ...........
90396.............. Varicella-zoster ig, im.. .................. K2................ ........... $122.74
90476.............. Adenovirus vaccine, type CH................ N1................ ........... ...........
4.
90477.............. Adenovirus vaccine, type CH................ N1................ ........... ...........
7.
90581.............. Anthrax vaccine, sc...... CH................ N1................ ........... ...........
90585.............. Bcg vaccine, percut...... .................. K2................ ........... $118.98
90632.............. Hep a vaccine, adult im.. CH................ N1................ ........... ...........
90633.............. Hep a vacc, ped/adol, 2 CH................ N1................ ........... ...........
dose.
90634.............. Hep a vacc, ped/adol, 3 CH................ N1................ ........... ...........
dose.
90636.............. Hep a/hep b vacc, adult CH................ N1................ ........... ...........
im.
90645.............. Hib vaccine, hboc, im.... CH................ N1................ ........... ...........
90646.............. Hib vaccine, prp-d, im... CH................ N1................ ........... ...........
90647.............. Hib vaccine, prp-omp, im. CH................ N1................ ........... ...........
90648.............. Hib vaccine, prp-t, im... CH................ N1................ ........... ...........
90665.............. Lyme disease vaccine, im. CH................ N1................ ........... ...........
90675.............. Rabies vaccine, im....... .................. K2................ ........... $150.80
90676.............. Rabies vaccine, id....... .................. K2................ ........... $119.86
90680.............. Rotovirus vacc 3 dose, CH................ N1................ ........... ...........
oral.
90690.............. Typhoid vaccine, oral.... CH................ N1................ ........... ...........
90691.............. Typhoid vaccine, im...... CH................ N1................ ........... ...........
90692.............. Typhoid vaccine, h-p, sc/ CH................ N1................ ........... ...........
id.
90698.............. Dtap-hib-ip vaccine, im.. CH................ N1................ ........... ...........
90700.............. Dtap vaccine, < 7 yrs, im CH................ N1................ ........... ...........
90701.............. Dtp vaccine, im.......... CH................ N1................ ........... ...........
90702.............. Dt vaccine < 7, im....... CH................ N1................ ........... ...........
90703.............. Tetanus vaccine, im...... CH................ N1................ ........... ...........
90704.............. Mumps vaccine, sc........ CH................ N1................ ........... ...........
90705.............. Measles vaccine, sc...... CH................ N1................ ........... ...........
90706.............. Rubella vaccine, sc...... CH................ N1................ ........... ...........
90707.............. Mmr vaccine, sc.......... CH................ N1................ ........... ...........
90708.............. Measles-rubella vaccine, .................. K2................ ........... $45.53
sc.
90710.............. Mmrv vaccine, sc......... CH................ N1................ ........... ...........
90712.............. Oral poliovirus vaccine.. CH................ N1................ ........... ...........
90713.............. Poliovirus, ipv, sc/im... CH................ N1................ ........... ...........
90714.............. Td vaccine no prsrv >/= 7 CH................ N1................ ........... ...........
im.
90715.............. Tdap vaccine >7 im....... CH................ N1................ ........... ...........
90717.............. Yellow fever vaccine, sc. CH................ N1................ ........... ...........
90718.............. Td vaccine > 7, im....... CH................ N1................ ........... ...........
90719.............. Diphtheria vaccine, im... CH................ N1................ ........... ...........
90720.............. Dtp/hib vaccine, im...... CH................ N1................ ........... ...........
90721.............. Dtap/hib vaccine, im..... CH................ N1................ ........... ...........
90725.............. Cholera vaccine, CH................ N1................ ........... ...........
injectable.
90727.............. Plague vaccine, im....... CH................ N1................ ........... ...........
90733.............. Meningococcal vaccine, sc .................. K2................ ........... $85.29
90734.............. Meningococcal vaccine, im .................. K2................ ........... $82.00
90735.............. Encephalitis vaccine, sc. .................. K2................ ........... $98.17
90749.............. Vaccine toxoid........... CH................ N1................ ........... ...........
A4218.............. Sterile saline or water.. .................. N1................ ........... ...........
A4220.............. Infusion pump refill kit. .................. N1................ ........... ...........
A4248.............. Chlorhexidine antisept... .................. N1................ ........... ...........
A4262.............. Temporary tear duct plug. .................. N1................ ........... ...........
A4263.............. Permanent tear duct plug. .................. N1................ ........... ...........
A4270.............. Disposable endoscope .................. N1................ ........... ...........
sheath.
A4300.............. Cath impl vasc access .................. N1................ ........... ...........
portal.
A4301.............. Implantable access syst .................. N1................ ........... ...........
perc.
A4305.............. Drug delivery system >=50 .................. N1................ ........... ...........
ML.
A4306.............. Drug delivery system <=50 .................. N1................ ........... ...........
ml.
A4648.............. Implantable tissue marker NI................ N1................ ........... ...........
A4650.............. Implant radiation NI................ N1................ ........... ...........
dosimeter.
A9527.............. Iodine I-125 sodium CH................ H2................ 0.4325 $27.55
iodide.
A9535.............. Injection, methylene blue CH................ N1................ ........... ...........
A9576.............. Inj prohance multipack... NI................ N1................ ........... ...........
A9577.............. Inj multihance........... NI................ N1................ ........... ...........
A9578.............. Inj multihance multipack. NI................ N1................ ........... ...........
A9579.............. Gad-base MR contrast NI................ N1................ ........... ...........
NOS,1ml.
A9698.............. Non-rad contrast .................. N1................ ........... ...........
materialNOC.
C1713.............. Anchor/screw bn/bn,tis/bn .................. N1................ ........... ...........
C1714.............. Cath, trans atherectomy, .................. N1................ ........... ...........
dir.
[[Page 67177]]
C1715.............. Brachytherapy needle..... .................. N1................ ........... ...........
C1716.............. Brachytx, non-str, Gold- CH................ H2................ 0.5228 $33.30
198.
C1717.............. Brachytx, non-str,HDR Ir- CH................ H2................ 2.7505 $175.19
192.
C1719.............. Brachytx, NS, Non-HDRIr- CH................ H2................ 1.0226 $65.13
192.
C1721.............. AICD, dual chamber....... .................. N1................ ........... ...........
C1722.............. AICD, single chamber..... .................. N1................ ........... ...........
C1724.............. Cath, trans .................. N1................ ........... ...........
atherec,rotation.
C1725.............. Cath, translumin non- .................. N1................ ........... ...........
laser.
C1726.............. Cath, bal dil, non- .................. N1................ ........... ...........
vascular.
C1727.............. Cath, bal tis dis, non- .................. N1................ ........... ...........
vas.
C1728.............. Cath, brachytx seed adm.. .................. N1................ ........... ...........
C1729.............. Cath, drainage........... .................. N1................ ........... ...........
C1730.............. Cath, EP, 19 or few elect .................. N1................ ........... ...........
C1731.............. Cath, EP, 20 or more elec .................. N1................ ........... ...........
C1732.............. Cath, EP, diag/abl, 3D/ .................. N1................ ........... ...........
vect.
C1733.............. Cath, EP, othr than cool- .................. N1................ ........... ...........
tip.
C1750.............. Cath, hemodialysis,long- .................. N1................ ........... ...........
term.
C1751.............. Cath, inf, per/cent/ .................. N1................ ........... ...........
midline.
C1752.............. Cath,hemodialysis,short- .................. N1................ ........... ...........
term.
C1753.............. Cath, intravas ultrasound .................. N1................ ........... ...........
C1754.............. Catheter, intradiscal.... .................. N1................ ........... ...........
C1755.............. Catheter, intraspinal.... .................. N1................ ........... ...........
C1756.............. Cath, pacing, transesoph. .................. N1................ ........... ...........
C1757.............. Cath, thrombectomy/ .................. N1................ ........... ...........
embolect.
C1758.............. Catheter, ureteral....... .................. N1................ ........... ...........
C1759.............. Cath, intra .................. N1................ ........... ...........
echocardiography.
C1760.............. Closure dev, vasc........ .................. N1................ ........... ...........
C1762.............. Conn tiss, human(inc .................. N1................ ........... ...........
fascia).
C1763.............. Conn tiss, non-human..... .................. N1................ ........... ...........
C1764.............. Event recorder, cardiac.. .................. N1................ ........... ...........
C1765.............. Adhesion barrier......... .................. N1................ ........... ...........
C1766.............. Intro/sheath,strble,non- .................. N1................ ........... ...........
peel.
C1767.............. Generator, neuro non- .................. N1................ ........... ...........
recharg.
C1768.............. Graft, vascular.......... .................. N1................ ........... ...........
C1769.............. Guide wire............... .................. N1................ ........... ...........
C1770.............. Imaging coil, MR, .................. N1................ ........... ...........
insertable.
C1771.............. Rep dev, urinary, w/sling .................. N1................ ........... ...........
C1772.............. Infusion pump, .................. N1................ ........... ...........
programmable.
C1773.............. Ret dev, insertable...... .................. N1................ ........... ...........
C1776.............. Joint device .................. N1................ ........... ...........
(implantable).
C1777.............. Lead, AICD, endo single .................. N1................ ........... ...........
coil.
C1778.............. Lead, neurostimulator.... .................. N1................ ........... ...........
C1779.............. Lead, pmkr, transvenous .................. N1................ ........... ...........
VDD.
C1780.............. Lens, intraocular (new .................. N1................ ........... ...........
tech).
C1781.............. Mesh (implantable)....... .................. N1................ ........... ...........
C1782.............. Morcellator.............. .................. N1................ ........... ...........
C1783.............. Ocular imp, aqueous drain .................. N1................ ........... ...........
de.
C1784.............. Ocular dev, intraop, det .................. N1................ ........... ...........
ret.
C1785.............. Pmkr, dual, rate-resp.... .................. N1................ ........... ...........
C1786.............. Pmkr, single, rate-resp.. .................. N1................ ........... ...........
C1787.............. Patient progr, neurostim. .................. N1................ ........... ...........
C1788.............. Port, indwelling, imp.... .................. N1................ ........... ...........
C1789.............. Prosthesis, breast, imp.. .................. N1................ ........... ...........
C1813.............. Prosthesis, penile, .................. N1................ ........... ...........
inflatab.
C1814.............. Retinal tamp, silicone .................. N1................ ........... ...........
oil.
C1815.............. Pros, urinary sph, imp... .................. N1................ ........... ...........
C1816.............. Receiver/transmitter, .................. N1................ ........... ...........
neuro.
C1817.............. Septal defect imp sys.... .................. N1................ ........... ...........
C1818.............. Integrated .................. N1................ ........... ...........
keratoprosthesis.
C1819.............. Tissue localization- .................. N1................ ........... ...........
excision.
C1820.............. Generator neuro rechg bat CH................ N1................ ........... ...........
sy.
C1821.............. Interspinous implant..... .................. J7................ ........... ...........
C1874.............. Stent, coated/cov w/del .................. N1................ ........... ...........
sys.
C1875.............. Stent, coated/cov w/o del .................. N1................ ........... ...........
sy.
C1876.............. Stent, non-coa/non-cov w/ .................. N1................ ........... ...........
del.
C1877.............. Stent, non-coat/cov w/o .................. N1................ ........... ...........
del.
C1878.............. Matrl for vocal cord..... .................. N1................ ........... ...........
C1879.............. Tissue marker, .................. N1................ ........... ...........
implantable.
[[Page 67178]]
C1880.............. Vena cava filter......... .................. N1................ ........... ...........
C1881.............. Dialysis access system... .................. N1................ ........... ...........
C1882.............. AICD, other than sing/ .................. N1................ ........... ...........
dual.
C1883.............. Adapt/ext, pacing/neuro .................. N1................ ........... ...........
lead.
C1884.............. Embolization Protect syst .................. N1................ ........... ...........
C1885.............. Cath, translumin angio .................. N1................ ........... ...........
laser.
C1887.............. Catheter, guiding........ .................. N1................ ........... ...........
C1888.............. Endovas non-cardiac abl .................. N1................ ........... ...........
cath.
C1891.............. Infusion pump,non-prog, .................. N1................ ........... ...........
perm.
C1892.............. Intro/sheath,fixed,peel- .................. N1................ ........... ...........
away.
C1893.............. Intro/sheath, fixed,non- .................. N1................ ........... ...........
peel.
C1894.............. Intro/sheath, non-laser.. .................. N1................ ........... ...........
C1895.............. Lead, AICD, endo dual .................. N1................ ........... ...........
coil.
C1896.............. Lead, AICD, non sing/dual .................. N1................ ........... ...........
C1897.............. Lead, neurostim test kit. .................. N1................ ........... ...........
C1898.............. Lead, pmkr, other than .................. N1................ ........... ...........
trans.
C1899.............. Lead, pmkr/AICD .................. N1................ ........... ...........
combination.
C1900.............. Lead, coronary venous.... .................. N1................ ........... ...........
C2614.............. Probe, perc lumb disc.... .................. N1................ ........... ...........
C2615.............. Sealant, pulmonary, .................. N1................ ........... ...........
liquid.
C2616.............. Brachytx, non-str,Yttrium- CH................ H2................ 184.7105 $11,764.95
90.
C2617.............. Stent, non-cor, tem w/o .................. N1................ ........... ...........
del.
C2618.............. Probe, cryoablation...... .................. N1................ ........... ...........
C2619.............. Pmkr, dual, non rate-resp .................. N1................ ........... ...........
C2620.............. Pmkr, single, non rate- .................. N1................ ........... ...........
resp.
C2621.............. Pmkr, other than sing/ .................. N1................ ........... ...........
dual.
C2622.............. Prosthesis, penile, non- .................. N1................ ........... ...........
inf.
C2625.............. Stent, non-cor, tem w/del .................. N1................ ........... ...........
sy.
C2626.............. Infusion pump, non- .................. N1................ ........... ...........
prog,temp.
C2627.............. Cath, suprapubic/ .................. N1................ ........... ...........
cystoscopic.
C2628.............. Catheter, occlusion...... .................. N1................ ........... ...........
C2629.............. Intro/sheath, laser...... .................. N1................ ........... ...........
C2630.............. Cath, EP, cool-tip....... .................. N1................ ........... ...........
C2631.............. Rep dev, urinary, w/o .................. N1................ ........... ...........
sling.
C2634.............. Brachytx, non-str, HA, I- CH................ H2................ 0.4858 $30.94
125.
C2635.............. Brachytx, non-str, HA, P- CH................ H2................ 0.7366 $46.92
103.
C2636.............. Brachy linear, non-str,P- CH................ H2................ 0.66 $42.04
103.
C2638.............. Brachytx, stranded, I-125 CH................ H2................ 0.7113 $45.31
C2639.............. Brachytx, non-stranded,I- CH................ H2................ 0.5039 $32.10
125.
C2640.............. Brachytx, stranded, P-103 CH................ H2................ 1.0308 $65.66
C2641.............. Brachytx, non-stranded,P- CH................ H2................ 0.8077 $51.45
103.
C2642.............. Brachytx, stranded, C-131 CH................ H2................ 1.5342 $97.72
C2643.............. Brachytx, non-stranded,C- CH................ H2................ 1.006 $64.08
131.
C2698.............. Brachytx, stranded, NOS.. CH................ H2................ 0.7113 $45.31
C2699.............. Brachytx, non-stranded, CH................ H2................ 0.4858 $30.94
NOS.
C8900.............. MRA w/cont, abd.......... .................. Z2................ 6.235 $258.14
C8901.............. MRA w/o cont, abd........ .................. Z2................ 5.3933 $223.29
C8902.............. MRA w/o fol w/cont, abd.. .................. Z2................ 8.2463 $341.41
C8903.............. MRI w/cont, breast, uni.. .................. Z2................ 6.235 $258.14
C8904.............. MRI w/o cont, breast, uni .................. Z2................ 5.3933 $223.29
C8905.............. MRI w/o fol w/cont, brst, .................. Z2................ 8.2463 $341.41
un.
C8906.............. MRI w/cont, breast, bi... .................. Z2................ 6.235 $258.14
C8907.............. MRI w/o cont, breast, bi. .................. Z2................ 5.3933 $223.29
C8908.............. MRI w/o fol w/cont, .................. Z2................ 8.2463 $341.41
breast,.
C8909.............. MRA w/cont, chest........ .................. Z2................ 6.235 $258.14
C8910.............. MRA w/o cont, chest...... .................. Z2................ 5.3933 $223.29
C8911.............. MRA w/o fol w/cont, chest .................. Z2................ 8.2463 $341.41
C8912.............. MRA w/cont, lwr ext...... .................. Z2................ 6.235 $258.14
C8913.............. MRA w/o cont, lwr ext.... .................. Z2................ 5.3933 $223.29
C8914.............. MRA w/o fol w/cont, lwr .................. Z2................ 8.2463 $341.41
ext.
C8918.............. MRA w/cont, pelvis....... .................. Z2................ 6.235 $258.14
C8919.............. MRA w/o cont, pelvis..... .................. Z2................ 5.3933 $223.29
C8920.............. MRA w/o fol w/cont, .................. Z2................ 8.2463 $341.41
pelvis.
C9003.............. Palivizumab, per 50 mg... .................. K2................ ........... $810.67
C9113.............. Inj pantoprazole sodium, .................. N1................ ........... ...........
via.
C9121.............. Injection, argatroban.... .................. K2................ ........... $18.96
C9232.............. Injection, idursulfase... CH................ D5................ ........... ...........
C9233.............. Injection, ranibizumab... CH................ D5................ ........... ...........
[[Page 67179]]
C9234.............. Inj, alglucosidase alfa.. CH................ D5................ ........... ...........
C9235.............. Injection, panitumumab... CH................ D5................ ........... ...........
C9238.............. Inj, levetiracetam....... NI................ K2................ ........... $6.30
C9239.............. Inj, temsirolimus........ NI................ K2................ ........... $48.41
C9350.............. Porous collagen tube per CH................ D5................ ........... ...........
cm.
C9351.............. Acellular derm tissue CH................ D5................ ........... ...........
percm2.
C9352.............. Neuragen nerve guide, per NI................ K2................ ........... $482.56
cm.
C9353.............. Neurawrap nerve NI................ K2................ ........... $482.56
protector,cm.
C9399.............. Unclassified drugs or .................. K7................ ........... ...........
biolog.
E0616.............. Cardiac event recorder... .................. N1................ ........... ...........
E0749.............. Elec osteogen stim .................. N1................ ........... ...........
implanted.
E0782.............. Non-programble infusion .................. N1................ ........... ...........
pump.
E0783.............. Programmable infusion .................. N1................ ........... ...........
pump.
E0785.............. Replacement impl pump .................. N1................ ........... ...........
cathet.
E0786.............. Implantable pump .................. N1................ ........... ...........
replacement.
G0130.............. Single energy x-ray study .................. Z3................ 0.5266 $21.80
G0173.............. Linear acc stereo radsur .................. Z2................ 61.6965 $2,554.30
com.
G0251.............. Linear acc based stero .................. Z2................ 16.5911 $686.89
radio.
G0288.............. Recon, CTA for surg plan. CH................ N1................ ........... ...........
G0339.............. Robot lin-radsurg com, .................. Z2................ 61.6965 $2,554.30
first.
G0340.............. Robt lin-radsurg fractx 2- .................. Z2................ 45.0693 $1,865.91
5.
J0120.............. Tetracyclin injection.... .................. N1................ ........... ...........
J0128.............. Abarelix injection....... .................. K2................ ........... $67.97
J0129.............. Abatacept injection...... .................. K2................ ........... $18.69
J0130.............. Abciximab injection...... .................. K2................ ........... $420.17
J0132.............. Acetylcysteine injection. CH................ N1................ ........... ...........
J0133.............. Acyclovir injection...... .................. N1................ ........... ...........
J0135.............. Adalimumab injection..... .................. K2................ ........... $329.58
J0150.............. Injection adenosine 6 MG. .................. K2................ ........... $25.10
J0152.............. Adenosine injection...... .................. K2................ ........... $67.89
J0170.............. Adrenalin epinephrin .................. N1................ ........... ...........
inject.
J0180.............. Agalsidase beta injection .................. K2................ ........... $126.00
J0190.............. Inj biperiden lactate/5 .................. K2................ ........... $88.15
mg.
J0200.............. Alatrofloxacin mesylate.. .................. N1................ ........... ...........
J0205.............. Alglucerase injection.... .................. K2................ ........... $38.85
J0207.............. Amifostine............... .................. K2................ ........... $490.93
J0210.............. Methyldopate hcl .................. K2................ ........... $13.04
injection.
J0215.............. Alefacept................ .................. K2................ ........... $26.47
J0220.............. Aglucosidase alfa NI................ K2................ ........... $126.00
injection.
J0256.............. Alpha 1 proteinase .................. K2................ ........... $3.28
inhibitor.
J0278.............. Amikacin sulfate .................. N1................ ........... ...........
injection.
J0280.............. Aminophyllin 250 MG inj.. .................. N1................ ........... ...........
J0282.............. Amiodarone HCl........... .................. N1................ ........... ...........
J0285.............. Amphotericin B........... .................. N1................ ........... ...........
J0287.............. Amphotericin b lipid .................. K2................ ........... $10.40
complex.
J0288.............. Ampho b cholesteryl .................. K2................ ........... $11.89
sulfate.
J0289.............. Amphotericin b liposome .................. K2................ ........... $16.21
inj.
J0290.............. Ampicillin 500 MG inj.... .................. N1................ ........... ...........
J0295.............. Ampicillin sodium per 1.5 .................. N1................ ........... ...........
gm.
J0300.............. Amobarbital 125 MG inj... .................. N1................ ........... ...........
J0330.............. Succinycholine chloride .................. N1................ ........... ...........
inj.
J0348.............. Anadulafungin injection.. .................. K2................ ........... $1.91
J0350.............. Injection anistreplase 30 .................. K2................ ........... $2,693.80
u.
J0360.............. Hydralazine hcl injection .................. N1................ ........... ...........
J0364.............. Apomorphine hydrochloride CH................ N1................ ........... ...........
J0365.............. Aprotonin, 10,000 kiu.... .................. K2................ ........... $2.66
J0380.............. Inj metaraminol CH................ N1................ ........... ...........
bitartrate.
J0390.............. Chloroquine injection.... .................. N1................ ........... ...........
J0395.............. Arbutamine HCl injection. CH................ N1................ ........... ...........
J0400.............. Aripiprazole injection... NI................ K2................ ........... $0.28
J0456.............. Azithromycin............. .................. N1................ ........... ...........
J0460.............. Atropine sulfate .................. N1................ ........... ...........
injection.
J0470.............. Dimecaprol injection..... .................. N1................ ........... ...........
J0475.............. Baclofen 10 MG injection. .................. K2................ ........... $193.29
J0476.............. Baclofen intrathecal .................. K2................ ........... $69.73
trial.
J0480.............. Basiliximab.............. .................. K2................ ........... $1,541.03
J0500.............. Dicyclomine injection.... .................. N1................ ........... ...........
J0515.............. Inj benztropine mesylate. .................. N1................ ........... ...........
[[Page 67180]]
J0520.............. Bethanechol chloride .................. N1................ ........... ...........
inject.
J0530.............. Penicillin g benzathine .................. N1................ ........... ...........
inj.
J0540.............. Penicillin g benzathine .................. N1................ ........... ...........
inj.
J0550.............. Penicillin g benzathine .................. N1................ ........... ...........
inj.
J0560.............. Penicillin g benzathine .................. N1................ ........... ...........
inj.
J0570.............. Penicillin g benzathine .................. N1................ ........... ...........
inj.
J0580.............. Penicillin g benzathine .................. N1................ ........... ...........
inj.
J0583.............. Bivalirudin.............. .................. K2................ ........... $1.84
J0585.............. Botulinum toxin a per .................. K2................ ........... $5.21
unit.
J0587.............. Botulinum toxin type B... .................. K2................ ........... $8.63
J0592.............. Buprenorphine .................. N1................ ........... ...........
hydrochloride.
J0594.............. Busulfan injection....... .................. K2................ ........... $9.17
J0595.............. Butorphanol tartrate 1 mg .................. N1................ ........... ...........
J0600.............. Edetate calcium disodium .................. K2................ ........... $49.64
inj.
J0610.............. Calcium gluconate .................. N1................ ........... ...........
injection.
J0620.............. Calcium glycer & lact/10 .................. N1................ ........... ...........
ML.
J0630.............. Calcitonin salmon .................. N1................ ........... ...........
injection.
J0636.............. Inj calcitriol per 0.1 .................. N1................ ........... ...........
mcg.
J0637.............. Caspofungin acetate...... .................. K2................ ........... $24.05
J0640.............. Leucovorin calcium .................. N1................ ........... ...........
injection.
J0670.............. Inj mepivacaine HCL/10 ml .................. N1................ ........... ...........
J0690.............. Cefazolin sodium .................. N1................ ........... ...........
injection.
J0692.............. Cefepime HCl for .................. N1................ ........... ...........
injection.
J0694.............. Cefoxitin sodium .................. N1................ ........... ...........
injection.
J0696.............. Ceftriaxone sodium .................. N1................ ........... ...........
injection.
J0697.............. Sterile cefuroxime .................. N1................ ........... ...........
injection.
J0698.............. Cefotaxime sodium .................. N1................ ........... ...........
injection.
J0702.............. Betamethasone acet&sod .................. N1................ ........... ...........
phosp.
J0704.............. Betamethasone sod phosp/4 .................. N1................ ........... ...........
MG.
J0706.............. Caffeine citrate CH................ N1................ ........... ...........
injection.
J0710.............. Cephapirin sodium .................. N1................ ........... ...........
injection.
J0713.............. Inj ceftazidime per 500 .................. N1................ ........... ...........
mg.
J0715.............. Ceftizoxime sodium / 500 .................. N1................ ........... ...........
MG.
J0720.............. Chloramphenicol sodium .................. N1................ ........... ...........
injec.
J0725.............. Chorionic gonadotropin/ .................. N1................ ........... ...........
1000u.
J0735.............. Clonidine hydrochloride.. .................. K2................ ........... $62.78
J0740.............. Cidofovir injection...... .................. K2................ ........... $754.39
J0743.............. Cilastatin sodium .................. N1................ ........... ...........
injection.
J0744.............. Ciprofloxacin iv......... .................. N1................ ........... ...........
J0745.............. Inj codeine phosphate /30 .................. N1................ ........... ...........
MG.
J0760.............. Colchicine injection..... .................. N1................ ........... ...........
J0770.............. Colistimethate sodium inj .................. N1................ ........... ...........
J0780.............. Prochlorperazine .................. N1................ ........... ...........
injection.
J0795.............. Corticorelin ovine .................. K2................ ........... $4.43
triflutal.
J0800.............. Corticotropin injection.. .................. K2................ ........... $169.77
J0835.............. Inj cosyntropin per 0.25 .................. K2................ ........... $64.01
MG.
J0850.............. Cytomegalovirus imm IV / .................. K2................ ........... $870.53
vial.
J0878.............. Daptomycin injection..... .................. K2................ ........... $0.35
J0881.............. Darbepoetin alfa, non- .................. K2................ ........... $2.88
esrd.
J0885.............. Epoetin alfa, non-esrd... .................. K2................ ........... $8.97
J0894.............. Decitabine injection..... .................. K2................ ........... $26.48
J0895.............. Deferoxamine mesylate inj CH................ N1................ ........... ...........
J0900.............. Testosterone enanthate .................. N1................ ........... ...........
inj.
J0945.............. Brompheniramine maleate .................. N1................ ........... ...........
inj.
J0970.............. Estradiol valerate .................. N1................ ........... ...........
injection.
J1000.............. Depo-estradiol cypionate .................. N1................ ........... ...........
inj.
J1020.............. Methylprednisolone 20 MG .................. N1................ ........... ...........
inj.
J1030.............. Methylprednisolone 40 MG .................. N1................ ........... ...........
inj.
J1040.............. Methylprednisolone 80 MG .................. N1................ ........... ...........
inj.
J1051.............. Medroxyprogesterone inj.. .................. N1................ ........... ...........
J1060.............. Testosterone cypionate 1 .................. N1................ ........... ...........
ML.
J1070.............. Testosterone cypionat 100 .................. N1................ ........... ...........
MG.
J1080.............. Testosterone cypionat 200 .................. N1................ ........... ...........
MG.
J1094.............. Inj dexamethasone acetate .................. N1................ ........... ...........
J1100.............. Dexamethasone sodium phos .................. N1................ ........... ...........
J1110.............. Inj dihydroergotamine .................. N1................ ........... ...........
mesylt.
J1120.............. Acetazolamid sodium .................. N1................ ........... ...........
injectio.
J1160.............. Digoxin injection........ .................. N1................ ........... ...........
[[Page 67181]]
J1162.............. Digoxin immune fab .................. K2................ ........... $478.88
(ovine).
J1165.............. Phenytoin sodium .................. N1................ ........... ...........
injection.
J1170.............. Hydromorphone injection.. .................. N1................ ........... ...........
J1180.............. Dyphylline injection..... .................. N1................ ........... ...........
J1190.............. Dexrazoxane HCl injection .................. K2................ ........... $162.11
J1200.............. Diphenhydramine hcl .................. N1................ ........... ...........
injectio.
J1205.............. Chlorothiazide sodium inj .................. K2................ ........... $141.07
J1212.............. Dimethyl sulfoxide 50% 50 .................. N1................ ........... ...........
ML.
J1230.............. Methadone injection...... .................. N1................ ........... ...........
J1240.............. Dimenhydrinate injection. .................. N1................ ........... ...........
J1245.............. Dipyridamole injection... .................. N1................ ........... ...........
J1250.............. Inj dobutamine HCL/250 mg .................. N1................ ........... ...........
J1260.............. Dolasetron mesylate...... .................. K2................ ........... $4.66
J1265.............. Dopamine injection....... .................. N1................ ........... ...........
J1270.............. Injection, .................. N1................ ........... ...........
doxercalciferol.
J1300.............. Eculizumab injection..... NI................ K2................ ........... $176.38
J1320.............. Amitriptyline injection.. .................. N1................ ........... ...........
J1324.............. Enfuvirtide injection.... .................. K2................ ........... $0.40
J1325.............. Epoprostenol injection... .................. N1................ ........... ...........
J1327.............. Eptifibatide injection... .................. K2................ ........... $17.67
J1330.............. Ergonovine maleate CH................ N1................ ........... ...........
injection.
J1335.............. Ertapenem injection...... .................. N1................ ........... ...........
J1364.............. Erythro lactobionate /500 .................. N1................ ........... ...........
MG.
J1380.............. Estradiol valerate 10 MG .................. N1................ ........... ...........
inj.
J1390.............. Estradiol valerate 20 MG .................. N1................ ........... ...........
inj.
J1410.............. Inj estrogen conjugate 25 .................. K2................ ........... $66.64
MG.
J1430.............. Ethanolamine oleate 100 .................. K2................ ........... $79.23
mg.
J1435.............. Injection estrone per 1 .................. N1................ ........... ...........
MG.
J1436.............. Etidronate disodium inj.. .................. K2................ ........... $70.73
J1438.............. Etanercept injection..... .................. K2................ ........... $167.12
J1440.............. Filgrastim 300 mcg .................. K2................ ........... $193.79
injection.
J1441.............. Filgrastim 480 mcg .................. K2................ ........... $298.39
injection.
J1450.............. Fluconazole.............. .................. N1................ ........... ...........
J1451.............. Fomepizole, 15 mg........ .................. K2................ ........... $12.80
J1452.............. Intraocular Fomivirsen na CH................ N1................ ........... ...........
J1455.............. Foscarnet sodium CH................ N1................ ........... ...........
injection.
J1457.............. Gallium nitrate injection CH................ K2................ ........... $1.61
J1458.............. Galsulfase injection..... .................. K2................ ........... $306.88
J1460.............. Gamma globulin 1 CC inj.. .................. K2................ ........... $11.91
J1470.............. Gamma globulin 2 CC inj.. CH................ K2................ ........... $23.82
J1480.............. Gamma globulin 3 CC inj.. CH................ K2................ ........... $35.72
J1490.............. Gamma globulin 4 CC inj.. CH................ K2................ ........... $47.64
J1500.............. Gamma globulin 5 CC inj.. CH................ K2................ ........... $59.54
J1510.............. Gamma globulin 6 CC inj.. CH................ K2................ ........... $71.50
J1520.............. Gamma globulin 7 CC inj.. CH................ K2................ ........... $83.30
J1530.............. Gamma globulin 8 CC inj.. CH................ K2................ ........... $95.27
J1540.............. Gamma globulin 9 CC inj.. CH................ K2................ ........... $107.25
J1550.............. Gamma globulin 10 CC inj. CH................ K2................ ........... $119.09
J1560.............. Gamma globulin > 10 CC CH................ K2................ ........... $119.09
inj.
J1561.............. Gamunex injection........ NI................ K2................ ........... $32.06
J1562.............. Vivaglobin, inj.......... .................. K2................ ........... $7.01
J1565.............. RSV-ivig................. .................. K2................ ........... $16.02
J1566.............. Immune globulin, powder.. .................. K2................ ........... $26.89
J1567.............. Immune globulin, liquid.. CH................ D5................ ........... ...........
J1568.............. Octagam injection........ NI................ K2................ ........... $33.19
J1569.............. Gammagard liquid NI................ K2................ ........... $31.06
injection.
J1570.............. Ganciclovir sodium .................. N1................ ........... ...........
injection.
J1571.............. Hepagam B IM injection... NI................ K2................ ........... $63.51
J1572.............. Flebogamma injection..... NI................ K2................ ........... $32.27
J1573.............. Hepagam B intravenous, NI................ K2................ ........... $63.51
inj.
J1580.............. Garamycin gentamicin inj. .................. N1................ ........... ...........
J1590.............. Gatifloxacin injection... .................. N1................ ........... ...........
J1595.............. Injection glatiramer CH................ K2................ ........... $52.04
acetate.
J1600.............. Gold sodium thiomaleate .................. N1................ ........... ...........
inj.
J1610.............. Glucagon hydrochloride/1 .................. K2................ ........... $68.84
MG.
J1620.............. Gonadorelin hydroch/ 100 .................. K2................ ........... $178.59
mcg.
J1626.............. Granisetron HCl injection .................. K2................ ........... $5.74
J1630.............. Haloperidol injection.... .................. N1................ ........... ...........
[[Page 67182]]
J1631.............. Haloperidol decanoate inj .................. N1................ ........... ...........
J1640.............. Hemin, 1 mg.............. .................. K2................ ........... $7.08
J1642.............. Inj heparin sodium per 10 .................. N1................ ........... ...........
u.
J1644.............. Inj heparin sodium per .................. N1................ ........... ...........
1000u.
J1645.............. Dalteparin sodium........ .................. N1................ ........... ...........
J1650.............. Inj enoxaparin sodium.... .................. N1................ ........... ...........
J1652.............. Fondaparinux sodium...... CH................ K2................ ........... $5.92
J1655.............. Tinzaparin sodium CH................ N1................ ........... ...........
injection.
J1670.............. Tetanus immune globulin .................. K2................ ........... $103.46
inj.
J1700.............. Hydrocortisone acetate .................. N1................ ........... ...........
inj.
J1710.............. Hydrocortisone sodium ph .................. N1................ ........... ...........
inj.
J1720.............. Hydrocortisone sodium .................. N1................ ........... ...........
succ i.
J1730.............. Diazoxide injection...... .................. K2................ ........... $113.24
J1740.............. Ibandronate sodium .................. K2................ ........... $138.96
injection.
J1742.............. Ibutilide fumarate .................. K2................ ........... $287.15
injection.
J1743.............. Idursulfase injection.... NI................ K2................ ........... $455.03
J1745.............. Infliximab injection..... .................. K2................ ........... $54.42
J1751.............. Iron dextran 165 .................. K2................ ........... $11.82
injection.
J1752.............. Iron dextran 267 .................. K2................ ........... $10.30
injection.
J1756.............. Iron sucrose injection... .................. K2................ ........... $0.36
J1785.............. Injection imiglucerase / .................. K2................ ........... $3.89
unit.
J1790.............. Droperidol injection..... .................. N1................ ........... ...........
J1800.............. Propranolol injection.... .................. N1................ ........... ...........
J1815.............. Insulin injection........ .................. N1................ ........... ...........
J1817.............. Insulin for insulin pump .................. N1................ ........... ...........
use.
J1830.............. Interferon beta-1b / .25 .................. K2................ ........... $106.57
MG.
J1835.............. Itraconazole injection... .................. K2................ ........... $39.68
J1840.............. Kanamycin sulfate 500 MG .................. N1................ ........... ...........
inj.
J1850.............. Kanamycin sulfate 75 MG .................. N1................ ........... ...........
inj.
J1885.............. Ketorolac tromethamine .................. N1................ ........... ...........
inj.
J1890.............. Cephalothin sodium .................. N1................ ........... ...........
injection.
J1931.............. Laronidase injection..... .................. K2................ ........... $23.64
J1940.............. Furosemide injection..... .................. N1................ ........... ...........
J1945.............. Lepirudin................ .................. K2................ ........... $159.44
J1950.............. Leuprolide acetate /3.75 .................. K2................ ........... $452.58
MG.
J1956.............. Levofloxacin injection... .................. N1................ ........... ...........
J1960.............. Levorphanol tartrate inj. .................. N1................ ........... ...........
J1980.............. Hyoscyamine sulfate inj.. .................. N1................ ........... ...........
J1990.............. Chlordiazepoxide .................. N1................ ........... ...........
injection.
J2001.............. Lidocaine injection...... .................. N1................ ........... ...........
J2010.............. Lincomycin injection..... .................. N1................ ........... ...........
J2020.............. Linezolid injection...... .................. K2................ ........... $25.17
J2060.............. Lorazepam injection...... .................. N1................ ........... ...........
J2150.............. Mannitol injection....... .................. N1................ ........... ...........
J2170.............. Mecasermin injection..... .................. K2................ ........... $15.62
J2175.............. Meperidine hydrochl /100 .................. N1................ ........... ...........
MG.
J2180.............. Meperidine/promethazine .................. N1................ ........... ...........
inj.
J2185.............. Meropenem................ CH................ N1................ ........... ...........
J2210.............. Methylergonovin maleate .................. N1................ ........... ...........
inj.
J2248.............. Micafungin sodium .................. K2................ ........... $1.44
injection.
J2250.............. Inj midazolam .................. N1................ ........... ...........
hydrochloride.
J2260.............. Inj milrinone lactate / 5 .................. N1................ ........... ...........
MG.
J2270.............. Morphine sulfate .................. N1................ ........... ...........
injection.
J2271.............. Morphine so4 injection .................. N1................ ........... ...........
100mg.
J2275.............. Morphine sulfate .................. N1................ ........... ...........
injection.
J2278.............. Ziconotide injection..... .................. K2................ ........... $6.46
J2280.............. Inj, moxifloxacin 100 mg. .................. N1................ ........... ...........
J2300.............. Inj nalbuphine .................. N1................ ........... ...........
hydrochloride.
J2310.............. Inj naloxone .................. N1................ ........... ...........
hydrochloride.
J2315.............. Naltrexone, depot form... .................. K2................ ........... $1.87
J2320.............. Nandrolone decanoate 50 .................. N1................ ........... ...........
MG.
J2321.............. Nandrolone decanoate 100 .................. N1................ ........... ...........
MG.
J2322.............. Nandrolone decanoate 200 .................. N1................ ........... ...........
MG.
J2323.............. Natalizumab injection.... NI................ K2................ ........... $7.51
J2325.............. Nesiritide injection..... .................. K2................ ........... $32.95
J2353.............. Octreotide injection, .................. K2................ ........... $99.04
depot.
J2354.............. Octreotide inj, non-depot .................. N1................ ........... ...........
J2355.............. Oprelvekin injection..... .................. K2................ ........... $247.02
[[Page 67183]]
J2357.............. Omalizumab injection..... .................. K2................ ........... $17.12
J2360.............. Orphenadrine injection... .................. N1................ ........... ...........
J2370.............. Phenylephrine hcl .................. N1................ ........... ...........
injection.
J2400.............. Chloroprocaine hcl .................. N1................ ........... ...........
injection.
J2405.............. Ondansetron hcl injection .................. K2................ ........... $0.26
J2410.............. Oxymorphone hcl injection .................. N1................ ........... ...........
J2425.............. Palifermin injection..... .................. K2................ ........... $11.24
J2430.............. Pamidronate disodium /30 .................. K2................ ........... $28.31
MG.
J2440.............. Papaverin hcl injection.. .................. N1................ ........... ...........
J2460.............. Oxytetracycline injection .................. N1................ ........... ...........
J2469.............. Palonosetron HCl......... .................. K2................ ........... $16.45
J2501.............. Paricalcitol............. .................. N1................ ........... ...........
J2503.............. Pegaptanib sodium .................. K2................ ........... $1,035.69
injection.
J2504.............. Pegademase bovine, 25 iu. .................. K2................ ........... $197.51
J2505.............. Injection, pegfilgrastim .................. K2................ ........... $2,145.12
6mg.
J2510.............. Penicillin g procaine inj .................. N1................ ........... ...........
J2513.............. Pentastarch 10% solution. CH................ K2................ ........... $21.98
J2515.............. Pentobarbital sodium inj. .................. N1................ ........... ...........
J2540.............. Penicillin g potassium .................. N1................ ........... ...........
inj.
J2543.............. Piperacillin/tazobactam.. .................. N1................ ........... ...........
J2550.............. Promethazine hcl .................. N1................ ........... ...........
injection.
J2560.............. Phenobarbital sodium inj. .................. N1................ ........... ...........
J2590.............. Oxytocin injection....... .................. N1................ ........... ...........
J2597.............. Inj desmopressin acetate. .................. N1................ ........... ...........
J2650.............. Prednisolone acetate inj. .................. N1................ ........... ...........
J2670.............. Totazoline hcl injection. .................. N1................ ........... ...........
J2675.............. Inj progesterone per 50 .................. N1................ ........... ...........
MG.
J2680.............. Fluphenazine decanoate 25 .................. N1................ ........... ...........
MG.
J2690.............. Procainamide hcl .................. N1................ ........... ...........
injection.
J2700.............. Oxacillin sodium .................. N1................ ........... ...........
injeciton.
J2710.............. Neostigmine methylslfte .................. N1................ ........... ...........
inj.
J2720.............. Inj protamine sulfate/10 .................. N1................ ........... ...........
MG.
J2724.............. Protein C concentrate.... NI................ K2................ ........... $12.08
J2725.............. Inj protirelin per 250 .................. N1................ ........... ...........
mcg.
J2730.............. Pralidoxime chloride inj. CH................ K2................ ........... $35.20
J2760.............. Phentolaine mesylate inj. .................. N1................ ........... ...........
J2765.............. Metoclopramide hcl .................. N1................ ........... ...........
injection.
J2770.............. Quinupristin/dalfopristin .................. K2................ ........... $126.44
J2778.............. Ranibizumab injection.... NI................ K2................ ........... $2,030.23
J2780.............. Ranitidine hydrochloride .................. N1................ ........... ...........
inj.
J2783.............. Rasburicase.............. .................. K2................ ........... $144.43
J2788.............. Rho d immune globulin 50 .................. K2................ ........... $26.41
mcg.
J2790.............. Rho d immune globulin inj .................. K2................ ........... $80.79
J2791.............. Rhophylac injection...... NI................ K2................ ........... $5.29
J2792.............. Rho(D) immune globulin h, .................. K2................ ........... $15.62
sd.
J2794.............. Risperidone, long acting. .................. K2................ ........... $4.86
J2795.............. Ropivacaine HCl injection .................. N1................ ........... ...........
J2800.............. Methocarbamol injection.. .................. N1................ ........... ...........
J2805.............. Sincalide injection...... .................. N1................ ........... ...........
J2810.............. Inj theophylline per 40 .................. N1................ ........... ...........
MG.
J2820.............. Sargramostim injection... .................. K2................ ........... $24.86
J2850.............. Inj secretin synthetic .................. K2................ ........... $20.12
human.
J2910.............. Aurothioglucose injeciton .................. N1................ ........... ...........
J2916.............. Na ferric gluconate .................. N1................ ........... ...........
complex.
J2920.............. Methylprednisolone .................. N1................ ........... ...........
injection.
J2930.............. Methylprednisolone .................. N1................ ........... ...........
injection.
J2940.............. Somatrem injection....... .................. K2................ ........... $168.90
J2941.............. Somatropin injection..... .................. K2................ ........... $48.52
J2950.............. Promazine hcl injection.. .................. N1................ ........... ...........
J2993.............. Reteplase injection...... .................. K2................ ........... $841.28
J2995.............. Inj streptokinase /250000 .................. K2................ ........... $129.75
IU.
J2997.............. Alteplase recombinant.... .................. K2................ ........... $33.39
J3000.............. Streptomycin injection... .................. N1................ ........... ...........
J3010.............. Fentanyl citrate .................. N1................ ........... ...........
injeciton.
J3030.............. Sumatriptan succinate / 6 .................. K2................ ........... $61.27
MG.
J3070.............. Pentazocine injection.... .................. N1................ ........... ...........
J3100.............. Tenecteplase injection... .................. K2................ ........... $2,034.65
J3105.............. Terbutaline sulfate inj.. .................. N1................ ........... ...........
[[Page 67184]]
J3120.............. Testosterone enanthate .................. N1................ ........... ...........
inj.
J3130.............. Testosterone enanthate .................. N1................ ........... ...........
inj.
J3140.............. Testosterone suspension .................. N1................ ........... ...........
inj.
J3150.............. Testosteron propionate .................. N1................ ........... ...........
inj.
J3230.............. Chlorpromazine hcl .................. N1................ ........... ...........
injection.
J3240.............. Thyrotropin injection.... .................. K2................ ........... $834.18
J3243.............. Tigecycline injection.... .................. K2................ ........... $0.96
J3246.............. Tirofiban HCl............ .................. K2................ ........... $7.56
J3250.............. Trimethobenzamide hcl inj .................. N1................ ........... ...........
J3260.............. Tobramycin sulfate .................. N1................ ........... ...........
injection.
J3265.............. Injection torsemide 10 mg/ .................. N1................ ........... ...........
ml.
J3280.............. Thiethylperazine maleate .................. N1................ ........... ...........
inj.
J3285.............. Treprostinil injection... .................. K2................ ........... $55.36
J3301.............. Triamcinolone acetonide .................. N1................ ........... ...........
inj.
J3302.............. Triamcinolone diacetate .................. N1................ ........... ...........
inj.
J3303.............. Triamcinolone hexacetonl .................. N1................ ........... ...........
inj.
J3305.............. Inj trimetrexate .................. K2................ ........... $148.30
glucoronate.
J3310.............. Perphenazine injeciton... .................. N1................ ........... ...........
J3315.............. Triptorelin pamoate...... .................. K2................ ........... $159.38
J3320.............. Spectinomycn di-hcl inj.. CH................ N1................ ........... ...........
J3350.............. Urea injection........... .................. K2................ ........... $74.16
J3355.............. Urofollitropin, 75 iu.... .................. K2................ ........... $50.22
J3360.............. Diazepam injection....... .................. N1................ ........... ...........
J3364.............. Urokinase 5000 IU .................. N1................ ........... ...........
injection.
J3365.............. Urokinase 250,000 IU inj. .................. K2................ ........... $453.41
J3370.............. Vancomycin hcl injection. .................. N1................ ........... ...........
J3396.............. Verteporfin injection.... .................. K2................ ........... $8.99
J3400.............. Triflupromazine hcl inj.. .................. N1................ ........... ...........
J3410.............. Hydroxyzine hcl injection .................. N1................ ........... ...........
J3411.............. Thiamine hcl 100 mg...... .................. N1................ ........... ...........
J3415.............. Pyridoxine hcl 100 mg.... .................. N1................ ........... ...........
J3420.............. Vitamin b12 injection.... .................. N1................ ........... ...........
J3430.............. Vitamin k phytonadione .................. N1................ ........... ...........
inj.
J3465.............. Injection, voriconazole.. .................. K2................ ........... $4.93
J3470.............. Hyaluronidase injection.. .................. N1................ ........... ...........
J3471.............. Ovine, up to 999 USP .................. N1................ ........... ...........
units.
J3472.............. Ovine, 1000 USP units.... .................. K2................ ........... $133.77
J3473.............. Hyaluronidase recombinant .................. K2................ ........... $0.40
J3475.............. Inj magnesium sulfate.... .................. N1................ ........... ...........
J3480.............. Inj potassium chloride... .................. N1................ ........... ...........
J3485.............. Zidovudine............... .................. N1................ ........... ...........
J3486.............. Ziprasidone mesylate..... .................. N1................ ........... ...........
J3487.............. Zoledronic acid.......... .................. K2................ ........... $205.76
J3488.............. Reclast injection........ NI................ K2................ ........... $220.81
J3490.............. Drugs unclassified .................. N1................ ........... ...........
injection.
J3530.............. Nasal vaccine inhalation. .................. N1................ ........... ...........
J3590.............. Unclassified biologics... .................. N1................ ........... ...........
J7030.............. Normal saline solution .................. N1................ ........... ...........
infus.
J7040.............. Normal saline solution .................. N1................ ........... ...........
infus.
J7042.............. 5% dextrose/normal saline .................. N1................ ........... ...........
J7050.............. Normal saline solution .................. N1................ ........... ...........
infus.
J7060.............. 5% dextrose/water........ .................. N1................ ........... ...........
J7070.............. D5w infusion............. .................. N1................ ........... ...........
J7100.............. Dextran 40 infusion...... .................. N1................ ........... ...........
J7110.............. Dextran 75 infusion...... .................. N1................ ........... ...........
J7120.............. Ringers lactate infusion. .................. N1................ ........... ...........
J7130.............. Hypertonic saline .................. N1................ ........... ...........
solution.
J7187.............. Humate-P, inj............ .................. K2................ ........... $0.88
J7189.............. Factor viia.............. .................. K2................ ........... $1.15
J7190.............. Factor viii.............. .................. K2................ ........... $0.75
J7191.............. Factor VIII (porcine).... CH................ N1................ ........... ...........
J7192.............. Factor viii recombinant.. .................. K2................ ........... $1.07
J7193.............. Factor IX non-recombinant .................. K2................ ........... $0.89
J7194.............. Factor ix complex........ .................. K2................ ........... $0.80
J7195.............. Factor IX recombinant.... .................. K2................ ........... $0.99
J7197.............. Antithrombin iii .................. K2................ ........... $1.82
injection.
J7198.............. Anti-inhibitor........... .................. K2................ ........... $1.42
J7308.............. Aminolevulinic acid hcl .................. K2................ ........... $109.92
top.
[[Page 67185]]
J7310.............. Ganciclovir long act .................. K2................ ........... $4,707.90
implant.
J7311.............. Fluocinolone acetonide .................. K2................ ........... $19,162.50
implt.
J7321.............. Hyalgan/supartz inj per NI................ K2................ ........... $101.81
dose.
J7322.............. Synvisc inj per dose..... NI................ K2................ ........... $178.11
J7323.............. Euflexxa inj per dose.... NI................ K2................ ........... $110.95
J7324.............. Orthovisc inj per dose... NI................ K2................ ........... $174.50
J7340.............. Metabolic active D/E .................. K2................ ........... $28.45
tissue.
J7341.............. Non-human, metabolic CH................ N1................ ........... ...........
tissue.
J7342.............. Metabolically active .................. K2................ ........... $36.40
tissue.
J7343.............. Nonmetabolic act d/e .................. K2................ ........... $20.22
tissue.
J7344.............. Nonmetabolic active .................. K2................ ........... $94.53
tissue.
J7345.............. Non-human, non-metab CH................ D5................ ........... ...........
tissue.
J7346.............. Injectable human tissue.. .................. K2................ ........... $774.46
J7347.............. Integra matrix tissue.... NI................ K2................ ........... $33.14
J7348.............. Tissuemend tissue........ NI................ K2................ ........... $67.96
J7349.............. Primatrix tissue......... NI................ K2................ ........... $67.96
J7500.............. Azathioprine oral 50mg... .................. N1................ ........... ...........
J7501.............. Azathioprine parenteral.. .................. K2................ ........... $47.88
J7502.............. Cyclosporine oral 100 mg. .................. K2................ ........... $3.52
J7504.............. Lymphocyte immune .................. K2................ ........... $336.10
globulin.
J7505.............. Monoclonal antibodies.... .................. K2................ ........... $977.75
J7506.............. Prednisone oral.......... .................. N1................ ........... ...........
J7507.............. Tacrolimus oral per 1 MG. .................. K2................ ........... $3.69
J7509.............. Methylprednisolone oral.. .................. N1................ ........... ...........
J7510.............. Prednisolone oral per 5 .................. N1................ ........... ...........
mg.
J7511.............. Antithymocyte globuln .................. K2................ ........... $337.82
rabbit.
J7513.............. Daclizumab, parenteral... .................. K2................ ........... $322.28
J7515.............. Cyclosporine oral 25 mg.. .................. N1................ ........... ...........
J7516.............. Cyclosporin parenteral .................. N1................ ........... ...........
250mg.
J7517.............. Mycophenolate mofetil .................. K2................ ........... $2.66
oral.
J7518.............. Mycophenolic acid........ .................. K2................ ........... $2.41
J7520.............. Sirolimus, oral.......... .................. K2................ ........... $7.50
J7525.............. Tacrolimus injection..... .................. K2................ ........... $138.64
J7599.............. Immunosuppressive drug .................. N1................ ........... ...........
noc.
J7674.............. Methacholine chloride, .................. N1................ ........... ...........
neb.
J7799.............. Non-inhalation drug for .................. N1................ ........... ...........
DME.
J8501.............. Oral aprepitant.......... .................. K2................ ........... $4.99
J8510.............. Oral busulfan............ .................. K2................ ........... $2.26
J8520.............. Capecitabine, oral, 150 .................. K2................ ........... $4.28
mg.
J8521.............. Capecitabine, oral, 500 CH................ K2................ ........... $14.19
mg.
J8530.............. Cyclophosphamide oral 25 .................. N1................ ........... ...........
MG.
J8540.............. Oral dexamethasone....... .................. N1................ ........... ...........
J8560.............. Etoposide oral 50 MG..... .................. K2................ ........... $29.46
J8597.............. Antiemetic drug oral NOS. .................. N1................ ........... ...........
J8600.............. Melphalan oral 2 MG...... CH................ K2................ ........... $4.14
J8610.............. Methotrexate oral 2.5 MG. .................. N1................ ........... ...........
J8650.............. Nabilone oral............ .................. K2................ ........... $16.80
J8700.............. Temozolomide............. .................. K2................ ........... $7.49
J9000.............. Doxorubic hcl 10 MG vl CH................ N1................ ........... ...........
chemo.
J9001.............. Doxorubicin hcl liposome .................. K2................ ........... $396.15
inj.
J9010.............. Alemtuzumab injection.... .................. K2................ ........... $549.77
J9015.............. Aldesleukin/single use .................. K2................ ........... $788.84
vial.
J9017.............. Arsenic trioxide......... .................. K2................ ........... $34.44
J9020.............. Asparaginase injection... .................. K2................ ........... $54.26
J9025.............. Azacitidine injection.... .................. K2................ ........... $4.35
J9027.............. Clofarabine injection.... .................. K2................ ........... $114.41
J9031.............. Bcg live intravesical vac .................. K2................ ........... $113.75
J9035.............. Bevacizumab injection.... .................. K2................ ........... $56.93
J9040.............. Bleomycin sulfate .................. K2................ ........... $42.93
injection.
J9041.............. Bortezomib injection..... .................. K2................ ........... $33.20
J9045.............. Carboplatin injection.... .................. K2................ ........... $7.44
J9050.............. Carmus bischl nitro inj.. .................. K2................ ........... $152.24
J9055.............. Cetuximab injection...... .................. K2................ ........... $49.43
J9060.............. Cisplatin 10 MG injection .................. N1................ ........... ...........
J9062.............. Cisplatin 50 MG injection CH................ N1................ ........... ...........
J9065.............. Inj cladribine per 1 MG.. .................. K2................ ........... $32.04
J9070.............. Cyclophosphamide 100 MG .................. N1................ ........... ...........
inj.
J9080.............. Cyclophosphamide 200 MG CH................ N1................ ........... ...........
inj.
[[Page 67186]]
J9090.............. Cyclophosphamide 500 MG CH................ N1................ ........... ...........
inj.
J9091.............. Cyclophosphamide 1.0 grm CH................ N1................ ........... ...........
inj.
J9092.............. Cyclophosphamide 2.0 grm CH................ N1................ ........... ...........
inj.
J9093.............. Cyclophosphamide CH................ N1................ ........... ...........
lyophilized.
J9094.............. Cyclophosphamide CH................ N1................ ........... ...........
lyophilized.
J9095.............. Cyclophosphamide CH................ N1................ ........... ...........
lyophilized.
J9096.............. Cyclophosphamide CH................ N1................ ........... ...........
lyophilized.
J9097.............. Cyclophosphamide CH................ N1................ ........... ...........
lyophilized.
J9098.............. Cytarabine liposome...... .................. K2................ ........... $412.21
J9100.............. Cytarabine hcl 100 MG inj .................. N1................ ........... ...........
J9110.............. Cytarabine hcl 500 MG inj CH................ N1................ ........... ...........
J9120.............. Dactinomycin actinomycin .................. K2................ ........... $488.78
d.
J9130.............. Dacarbazine 100 mg inj... CH................ N1................ ........... ...........
J9140.............. Dacarbazine 200 MG inj... CH................ N1................ ........... ...........
J9150.............. Daunorubicin............. .................. K2................ ........... $19.33
J9151.............. Daunorubicin citrate .................. K2................ ........... $55.23
liposom.
J9160.............. Denileukin diftitox, 300 .................. K2................ ........... $1,386.59
mcg.
J9165.............. Diethylstilbestrol .................. N1................ ........... ...........
injection.
J9170.............. Docetaxel................ .................. K2................ ........... $310.85
J9175.............. Elliotts b solution per .................. N1................ ........... ...........
ml.
J9178.............. Inj, epirubicin hcl, 2 mg .................. K2................ ........... $19.79
J9181.............. Etoposide 10 MG inj...... .................. N1................ ........... ...........
J9182.............. Etoposide 100 MG inj..... CH................ N1................ ........... ...........
J9185.............. Fludarabine phosphate inj .................. K2................ ........... $226.67
J9190.............. Fluorouracil injection... .................. N1................ ........... ...........
J9200.............. Floxuridine injection.... .................. K2................ ........... $54.63
J9201.............. Gemcitabine HCl.......... .................. K2................ ........... $127.31
J9202.............. Goserelin acetate implant .................. K2................ ........... $192.29
J9206.............. Irinotecan injection..... .................. K2................ ........... $124.61
J9208.............. Ifosfomide injection..... .................. K2................ ........... $38.13
J9209.............. Mesna injection.......... .................. K2................ ........... $7.97
J9211.............. Idarubicin hcl injection. .................. K2................ ........... $302.42
J9212.............. Interferon alfacon-1..... .................. K2................ ........... $4.62
J9213.............. Interferon alfa-2a inj... .................. K2................ ........... $41.37
J9214.............. Interferon alfa-2b inj... .................. K2................ ........... $13.92
J9215.............. Interferon alfa-n3 inj... .................. K2................ ........... $9.03
J9216.............. Interferon gamma 1-b inj. .................. K2................ ........... $306.66
J9217.............. Leuprolide acetate .................. K2................ ........... $236.06
suspnsion.
J9218.............. Leuprolide acetate .................. K2................ ........... $7.98
injeciton.
J9219.............. Leuprolide acetate .................. K2................ ........... $1,648.41
implant.
J9225.............. Vantas implant........... .................. K2................ ........... $1,412.46
J9226.............. Supprelin LA implant..... NI................ K2................ ........... $14,700.00
J9230.............. Mechlorethamine hcl inj.. .................. K2................ ........... $143.08
J9245.............. Inj melphalan hydrochl 50 .................. K2................ ........... $1,548.88
MG.
J9250.............. Methotrexate sodium inj.. .................. N1................ ........... ...........
J9260.............. Methotrexate sodium inj.. CH................ N1................ ........... ...........
J9261.............. Nelarabine injection..... .................. K2................ ........... $86.84
J9263.............. Oxaliplatin.............. .................. K2................ ........... $9.15
J9264.............. Paclitaxel protein bound. .................. K2................ ........... $8.79
J9265.............. Paclitaxel injection..... .................. K2................ ........... $14.57
J9266.............. Pegaspargase/singl dose .................. K2................ ........... $2,080.19
vial.
J9268.............. Pentostatin injection.... .................. K2................ ........... $2,051.68
J9270.............. Plicamycin (mithramycin) .................. K2................ ........... $172.41
inj.
J9280.............. Mitomycin 5 MG inj....... .................. K2................ ........... $14.39
J9290.............. Mitomycin 20 MG inj...... CH................ K2................ ........... $57.56
J9291.............. Mitomycin 40 MG inj...... CH................ K2................ ........... $115.11
J9293.............. Mitoxantrone hydrochl / 5 .................. K2................ ........... $107.96
MG.
J9300.............. Gemtuzumab ozogamicin.... .................. K2................ ........... $2,411.98
J9303.............. Panitumumab injection.... NI................ K2................ ........... $83.15
J9305.............. Pemetrexed injection..... .................. K2................ ........... $44.49
J9310.............. Rituximab cancer .................. K2................ ........... $504.40
treatment.
J9320.............. Streptozocin injection... .................. K2................ ........... $146.93
J9340.............. Thiotepa injection....... .................. K2................ ........... $41.12
J9350.............. Topotecan................ .................. K2................ ........... $859.62
J9355.............. Trastuzumab.............. .................. K2................ ........... $58.51
J9357.............. Valrubicin, 200 mg....... .................. K2................ ........... $77.96
J9360.............. Vinblastine sulfate inj.. .................. N1................ ........... ...........
J9370.............. Vincristine sulfate 1 MG .................. N1................ ........... ...........
inj.
[[Page 67187]]
J9375.............. Vincristine sulfate 2 MG CH................ N1................ ........... ...........
inj.
J9380.............. Vincristine sulfate 5 MG CH................ N1................ ........... ...........
inj.
J9390.............. Vinorelbine tartrate/10 .................. K2................ ........... $21.41
mg.
J9395.............. Injection, Fulvestrant... .................. K2................ ........... $80.60
J9600.............. Porfimer sodium.......... .................. K2................ ........... $2,532.53
J9999.............. Chemotherapy drug........ .................. N1................ ........... ...........
L8600.............. Implant breast silicone/ .................. N1................ ........... ...........
eq.
L8603.............. Collagen imp urinary 2.5 .................. N1................ ........... ...........
ml.
L8606.............. Synthetic implnt urinary .................. N1................ ........... ...........
1ml.
L8609.............. Artificial cornea........ .................. N1................ ........... ...........
L8610.............. Ocular implant........... .................. N1................ ........... ...........
L8612.............. Aqueous shunt prosthesis. .................. N1................ ........... ...........
L8613.............. Ossicular implant........ .................. N1................ ........... ...........
L8614.............. Cochlear device.......... .................. N1................ ........... ...........
L8630.............. Metacarpophalangeal .................. N1................ ........... ...........
implant.
L8631.............. MCP joint repl 2 pc or .................. N1................ ........... ...........
more.
L8641.............. Metatarsal joint implant. .................. N1................ ........... ...........
L8642.............. Hallux implant........... .................. N1................ ........... ...........
L8658.............. Interphalangeal joint .................. N1................ ........... ...........
spacer.
L8659.............. Interphalangeal joint .................. N1................ ........... ...........
repl.
L8670.............. Vascular graft, synthetic .................. N1................ ........... ...........
L8682.............. Implt neurostim radiofq .................. N1................ ........... ...........
rec.
L8690.............. Aud osseo dev, int/ext .................. J7................ ........... ...........
comp.
L8699.............. Prosthetic implant NOS... .................. N1................ ........... ...........
P9041.............. Albumin (human),5%, 50ml. CH................ K2................ 0.3413 $21.74
P9045.............. Albumin (human), 5%, 250 CH................ K2................ 1.0987 $69.98
ml.
P9046.............. Albumin (human), 25%, 20 CH................ K2................ 0.4118 $26.23
ml.
P9047.............. Albumin (human), 25%, CH................ K2................ 1.1362 $72.37
50ml.
Q0163.............. Diphenhydramine HCl 50mg. .................. N1................ ........... ...........
Q0164.............. Prochlorperazine maleate .................. N1................ ........... ...........
5mg.
Q0166.............. Granisetron HCl 1 mg oral .................. K2................ ........... $49.96
Q0167.............. Dronabinol 2.5mg oral.... .................. N1................ ........... ...........
Q0169.............. Promethazine HCl 12.5mg .................. N1................ ........... ...........
oral.
Q0171.............. Chlorpromazine HCl 10mg .................. N1................ ........... ...........
oral.
Q0173.............. Trimethobenzamide HCl .................. N1................ ........... ...........
250mg.
Q0174.............. Thiethylperazine .................. N1................ ........... ...........
maleate10mg.
Q0175.............. Perphenazine 4mg oral.... .................. N1................ ........... ...........
Q0177.............. Hydroxyzine pamoate 25mg. .................. N1................ ........... ...........
Q0179.............. Ondansetron HCl 8mg oral. .................. K2................ ........... $18.37
Q0180.............. Dolasetron mesylate oral. .................. K2................ ........... $43.77
Q0515.............. Sermorelin acetate .................. K2................ ........... $1.74
injection.
Q1003.............. Ntiol category 3......... .................. L6................ ........... $50.00
Q2004.............. Bladder calculi irrig sol .................. N1................ ........... ...........
Q2009.............. Fosphenytoin, 50 mg...... .................. K2................ ........... $5.76
Q2017.............. Teniposide, 50 mg........ .................. K2................ ........... $280.26
Q3025.............. IM inj interferon beta 1- .................. K2................ ........... $118.84
a.
Q4079.............. Natalizumab injection.... CH................ D5................ ........... ...........
Q4083.............. Hyalgan/supartz inj per CH................ D5................ ........... ...........
dose.
Q4084.............. Synvisc inj per dose..... CH................ D5................ ........... ...........
Q4085.............. Euflexxa inj per dose.... CH................ D5................ ........... ...........
Q4086.............. Orthovisc inj per dose... CH................ D5................ ........... ...........
Q4087.............. Octagam injection........ CH................ D5................ ........... ...........
Q4088.............. Gammagard liquid CH................ D5................ ........... ...........
injection.
Q4089.............. Rhophylac injection...... CH................ D5................ ........... ...........
Q4090.............. Hepagam B IM injection... CH................ D5................ ........... ...........
Q4091.............. Flebogamma injection..... CH................ D5................ ........... ...........
Q4092.............. Gamunex injection........ CH................ D5................ ........... ...........
Q4095.............. Reclast injection........ CH................ D5................ ........... ...........
Q9945.............. LOCM <=149 mg/ml iodine, CH................ D5................ ........... ...........
1ml.
Q9946.............. LOCM 150-199mg/ml CH................ D5................ ........... ...........
iodine,1ml.
Q9947.............. LOCM 200-249mg/ml CH................ D5................ ........... ...........
iodine,1ml.
Q9948.............. LOCM 250-299mg/ml CH................ D5................ ........... ...........
iodine,1ml.
Q9949.............. LOCM 300-349mg/ml CH................ D5................ ........... ...........
iodine,1ml.
Q9950.............. LOCM 350-399mg/ml CH................ D5................ ........... ...........
iodine,1ml.
Q9951.............. LOCM >= 400 mg/ml CH................ N1................ ........... ...........
iodine,1ml.
Q9952.............. Inj Gad-base MR CH................ D5................ ........... ...........
contrast,1ml.
Q9953.............. Inj Fe-based MR CH................ N1................ ........... ...........
contrast,1ml.
Q9954.............. Oral MR contrast,100 ml.. CH................ N1................ ........... ...........
[[Page 67188]]
Q9955.............. Inj perflexane lip CH................ N1................ ........... ...........
micros,ml.
Q9956.............. Inj octafluoropropane CH................ N1................ ........... ...........
mic,ml.
Q9957.............. Inj perflutren lip CH................ N1................ ........... ...........
micros,ml.
Q9958.............. HOCM <=149 mg/ml .................. N1................ ........... ...........
iodine,1ml.
Q9959.............. HOCM 150-199mg/ml .................. N1................ ........... ...........
iodine,1ml.
Q9960.............. HOCM 200-249mg/ml .................. N1................ ........... ...........
iodine,1ml.
Q9961.............. HOCM 250-299mg/ml .................. N1................ ........... ...........
iodine,1ml.
Q9962.............. HOCM 300-349mg/ml .................. N1................ ........... ...........
iodine,1ml.
Q9963.............. HOCM 350-399mg/ml .................. N1................ ........... ...........
iodine,1ml.
Q9964.............. HOCM>= 400mg/ml .................. N1................ ........... ...........
iodine,1ml.
Q9965.............. LOCM 100-199mg/ml NI................ N1................ ........... ...........
iodine,1ml.
Q9966.............. LOCM 200-299mg/ml NI................ N1................ ........... ...........
iodine,1ml.
Q9967.............. LOCM 300-399mg/ml NI................ N1................ ........... ...........
iodine,1ml.
V2630.............. Anter chamber intraocul .................. N1................ ........... ...........
lens.
V2631.............. Iris support intraoclr .................. N1................ ........... ...........
lens.
V2632.............. Post chmbr intraocular .................. N1................ ........... ...........
lens.
V2785.............. Corneal tissue processing .................. F4................ ........... ...........
V2790.............. Amniotic membrane........ .................. N1................ ........... ...........
----------------------------------------------------------------------------------------------------------------
Addendum D1.--OPPS Payment Status Indicators
------------------------------------------------------------------------
OPPS payment
Indicator Item/code/service status
------------------------------------------------------------------------
A............................... Services furnished Not paid under
to a hospital OPPS. Paid by
outpatient that fiscal
are paid under a intermediaries/
fee schedule or MACs under a fee
payment system schedule or
other than OPPS, payment system
for example: other than OPPS.
Ambulance
Services.
Clinical Not subject to
Diagnostic deductible or
Laboratory coinsurance.
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 Not subject to
Mammography. deductible.
------------------------------------------------------------------------
B............................... Codes that are not Not paid under
recognized by OPPS.
OPPS when
submitted on an
outpatient
hospital Part B
bill type (12x
and 13x).
May be
paid by fiscal
intermediaries/
MACs when
submitted on a
different bill
type, 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 Not paid under
Procedures. 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
Services: OPPS or any other
Medicare payment
system.
That are
not covered by
Medicare based on
statutory
exclusion.
That are
not covered by
Medicare for
reasons other
than statutory
exclusion.