[Federal Register Volume 76, Number 108 (Monday, June 6, 2011)]
[Proposed Rules]
[Pages 32410-32813]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-13052]



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Vol. 76

Monday,

No. 108

June 6, 2011

Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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42 CFR Part 414



Medicare Program; Five-Year Review of Work Relative Value Units Under 
the Physician Fee Schedule; Proposed Rule

  Federal Register / Vol. 76 , No. 108 / Monday, June 6, 2011 / 
Proposed Rules  

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 414

[CMS-1582-PN]
RIN 0938-AQ87


Medicare Program; Five-Year Review of Work Relative Value Units 
Under the Physician Fee Schedule

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

ACTION: Proposed notice.

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SUMMARY: This proposed notice sets forth proposed revisions to work 
relative value units (RVUs) and corresponding changes to the practice 
expense and malpractice RVUs affecting payment for physicians' 
services. The statute requires that we review RVUs no less often than 
every 5 years. This is our Fourth Five-Year Review of Work RVUs since 
we implemented the physician fee schedule (PFS) on January 1, 1992. 
These revisions to work RVUs are proposed to be effective for services 
furnished beginning January 1, 2012. These revisions reflect changes in 
medical practice and coding that affect the relative amount of 
physician work required to perform each service as required by the 
statute. The Fourth Five-Year Review of Work includes services that 
were submitted through public comment and by the Medicare contractor 
medical directors (CMDs), as well as a number of potentially misvalued 
codes identified by CMS (that is, Harvard valued codes and codes with 
Site-of-Service anomalies).

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on July 25, 2011.

ADDRESSES: In commenting, please refer to file code CMS-1582-PN. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed).
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the ``Submit a 
comment'' instructions.
    2. By regular mail. You may mail written comments to the following 
address only: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-1582-PN, P.O. Box 8013, 
Baltimore, MD 21244-8013.
    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 to 
the following address only: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-1582-PN, 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 before the close of the comment period 
to either of the following addresses:
    a. For delivery in Washington, DC--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 
20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 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.
    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.

FOR FURTHER INFORMATION CONTACT: Erin Smith, (410) 786-4497, for issues 
related to physician payment and for all other issues not identified 
below.
    Elizabeth Truong, (410) 786-6005, or Sara Vitolo, (410) 786-5714, 
for issues related to work RVUs.
    Ryan Howe, (410) 786-3355, for issues related to PE RVUs.

SUPPLEMENTARY INFORMATION: 
    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://regulations.gov. Follow the search instructions on that Web site to 
view public comments.
    Comments received timely will be also 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, Maryland 21244, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

Table of Contents

I. Background
    A. History
    B. Physician Fee Schedule Rulemaking
    C. The Five-Year Review Process
    1. Identification of CPT Codes for Review
    2. Background on American Medical Association/Specialty Society 
Relative Value Update Committee (AMA RUC) Recommendations AMA RUC
    3. Five-Year Review of Work Process
II. CMS Review of Five-Year Review Codes
    A. CMS Analytical Approach
    B. Summary of Proposed Work RVUs for Five-Year Review Codes
    C. Code-Specific Discussions of Proposed Alternative Work RVUs
    1. Drainage of Hematoma
    2. Wound Repair
    3. Skin Grafts
    4. Destruction of Skin Lesions
    5. Partial Mastectomy
    6. Percutaneous Vertebroplasty/Kyphoplasty
    7. Closed Treatment of Distal Radial Fracture
    8. Orthopaedic Surgery--Thigh/Knee
    9. Treatment of Ankle Fracture
    10. Orthopaedic Surgery/Podiatry
    11. Application of Cast and Strapping
    12. Cardiothoracic Surgery
    13. Vascular Surgery
    14. Excise Parotid Gland/Lesion
    15. Endoscopic Cholangiopancreatography
    16. Sigmoidoscopy
    17. Laparoscopic Cholecystectomy
    18. Hernia Repair
    19. Laparoscopic Hernia Repair
    20. Urologic Procedures
    21. Removal of Thyroid/Parathyroid
    22. Implant Neuroelectrodes
    23. Injection of Anesthetic Agent
    24. Gastric Emptying Study
    25. Nasopharyngoscopy
    26. Cardiopulmonary Resuscitation
    27. Osteopathic Manipulative Treatment
    28. Observation Care
    D. HCPAC-Recommended Work RVUs--Excision of Nail
    E. CPT Codes Identified Through the Five-Year Review Process, 
But Not Reviewed by CMS
    1. CPT Codes Referred to CPT Editorial Board
    2. CPT Codes Withdrawn From the Five-Year Review

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    3. CPT Codes That Are Interim Final for CY 2011
    4. CPT Codes for Preventive Medicine Services
    F. Resource-Based Practice Expense RVUs
    1. Overview
    2. Practice Expense Methodology
    a. Direct Practice Expense
    b. Indirect Practice Expense per Hour Data
    c. Allocation of Practice Expense to Services
    d. Facility and Nonfacility Costs
    e. Services With Technical Components and Professional 
Components
    f. Practice Expense RVU Methodology
    3. Practice Expense RVUs for Codes Included in the Five-Year 
Review
    a. Changes to Direct Practice Expense Inputs
    (1) Changes in Intra-Service Physician Time in the Nonfacility 
Setting
    (2) Changes in Hospital Discharge Management Services in the 
Facility Setting
    (3) Changes in the Number or Level of Postoperative Office 
Visits in the Global Period
    b. Changes in Components of the Indirect Practice Expense 
Methodology
    (1) Work RVUs, Direct PE RVUs, and Clinical Labor PE RVUs
    (2) Physician Time
    G. Malpractice RVUs
III. Budget Neutrality
IV. Collection of Information Requirements
V. Regulatory Impact Analysis
    A. Overall Impact
    B. Anticipated Effects: Impact on Beneficiaries
    C. Alternatives Considered
    D. Accounting Statement and Table
    E. Conclusion
Addendum A: Explanation and Use of Addendum B
Addendum B: Relative Value Units and Related Information
Addendum C: Codes With Work RVUs Subject to Comment

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

AAD American Academy of Dermatology
AAN American Academy of Neurology
AANEM American Association of Neuromuscular and Electrodiagnostic 
Medicine
AAFP American Academy of Family Physicians
AAGP American Association for Geriatric Psychiatry
AAHCP American Academy of Home Care Physicians
AANS American Association of Neurological Surgeons
AAO American Academy of Ophthalmology
AAO-HNS American Academy of Otolaryngology--Head and Neck Surgery
AAOA American Academy of Otolaryngic Allergy
AAOS American Academy of Orthopaedic Surgeons
AAP American Academy of Pediatrics
AAPM American Academy of Pain Medicine
AAPMR American Academy of Physical Medicine and Rehabilitation
AATS American Association for Thoracic Surgery
ACC American College of Cardiology
ACG American College of Gastroenterology
ACNS American Clinical Neurophysiology Society
ACOG American College of Obstetricians and Gynecologists
ACR American College of Radiology
ACS American College of Surgeons
AFROC Association of Freestanding Radiation Oncology Centers
AGA American Gastroenterological Association
AGS American Geriatric Society
AK Actinic keratoses
AMA American Medical Association
AMDA American Medical Directors Association
AOA American Optometric Association
ASA American Society of Anesthesiologists
ASC Ambulatory surgical center
ASCRS American Society of Colon and Rectal Surgeons
ASGE American Society of Gastrointestinal Endoscopy
ASHA American Speech-Language-Hearing Association
ASPS American Society of Plastic Surgeons
ASSH American Society for Surgery of the Hand
ASTRO American Society for Therapeutic Radiology and Oncology
AUA American Urological Association
BBA 97 Balanced Budget Act of 1997 (Pub. L. 105-33)
BBRA [Medicare, Medicaid and State Child Health Insurance Program] 
Balanced Budget Refinement Act of 1999 (Pub. L. 106-113)
BNF Budget neutrality factor
CAPU Coalition for the Advancement of Prosthetic Urology
CF Conversion factor
CNS Congress of Neurological Surgeons
CPEP Clinical Practice Expert Panels
CPT Current Procedural Terminology
CY Calendar year
DRG Diagnosis-Related Group
E/M Evaluation and management
FR Federal Register
HCPAC Health Care Professionals Advisory Committee
HCPCS Healthcare Common Procedure Coding System
HHS Health and Human Services
ICU Intensive care unit
IDTF Independent diagnostic testing facility
IWPUT Intra-service work per unit of time
JCAAI Joint Council of Allergy, Asthma, and Immunology
MMA Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003 (Pub. L. 108-173)
MMSV Minimum multi-specialty visit
MPC [the RUC's] Multi-Specialty Points of Comparison
NCQDIS National Coalition of Quality Diagnostic Imaging Services
NPWP Non-physician work pool
NSQIP National Surgical Quality Improvement Program
PC Professional component
PE Practice Expense
PE/HR Practice expense per hour
PEAC Practice Expense Advisory Committee
PERC Practice Expense Review Committee
PFS Physician fee schedule
RFA Regulatory Flexibility Act
RIA Regulatory impact analysis
RN Registered nurse
RUC [AMA's Specialty Society] Relative [Value] Update Committee
RVU Relative value unit
SMS [AMA's] Socioeconomic Monitoring System
SNF Skilled nursing facility
STS Society of Thoracic Surgeons
SVS Society for Vascular Surgery
TC Technical component
VA [Department of] Veteran Affairs

CPT (Current Procedural Terminology) Copyright Notice

    Throughout this proposed rule, we use CPT codes and descriptions to 
refer to a variety of services. We note that CPT codes and descriptions 
are copyright 2010 American Medical Association. All Rights Reserved. 
CPT is a registered trademark of the American Medical Association 
(AMA). Applicable FARS/DFARS apply.

I. Background

A. History

    Since January 1, 1992, Medicare has paid for physicians' services 
under section 1848 of the Social Security Act (the Act), ``Payment for 
Physicians' Services.'' Section 1848 of the Act contains three major 
elements: (1) A fee schedule for the payment of physicians' services; 
(2) a sustainable growth rate for the rates of increase in Medicare 
expenditures for physicians' services; and (3) limits on the amounts 
that nonparticipating physicians can charge beneficiaries. The Act 
requires that payments under the fee schedule be based on national 
uniform relative value units (RVUs) based on the resources used in 
furnishing a service. Section 1848(c) of the Act requires that national 
RVUs be established for physician work, practice expense (PE), and 
malpractice expense. In order to establish physician work, PE, and 
malpractice expense RVUs, section 1848(c)(2)(K)(iii) of the Act (as 
added by section 3134 of the Patient Protection and Affordable Care Act 
(Pub. L. 111-148) (hereinafter the ``Affordable Care Act'') also 
specifies that the Secretary may use existing processes to receive 
recommendations on the review and appropriate adjustment of potentially 
misvalued services. Section 1848(c)(2)(B)(i) of the Act requires that 
we review RVUs no less often than every 5 years.
    The statute also specifies a budget neutrality requirement. 
Specifically,

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section 1848(c)(2)(B)(ii)(II) of the Act requires that increases or 
decreases in RVUs may not cause the amount of expenditures under Part B 
for the year to differ more than $20 million from what it would have 
been in the absence of these changes. If this threshold is exceeded, we 
are required to make adjustments to preserve budget neutrality.

B. Physician Fee Schedule Rulemaking

    On an annual basis, we publish regulations relating to updates to 
the RVUs and revisions to the payment policies under the PFS. Most 
recently, in the calendar year (CY) 2011 PFS final rule with comment 
period that was published in the Federal Register on November 29, 2010 
(75 FR 73170) (hereinafter referred to as the CY 2011 PFS final rule 
with comment period), we finalized most of the CY 2010 interim 
physician work, PE, and malpractice RVUs; issued new interim work, PE, 
and malpractice RVUs for new and revised codes for CY 2011; and 
finalized several other payment policies related to the PFS. In the 
January 11, 2011 Federal Register (76 FR 1670), we published a 
correction notice that identified and corrected a number of technical 
and typographical errors in the CY 2011 PFS final rule with comment 
period. The provisions of the correction notice were effective January 
1, 2010.
    As noted previously, section 1848(c)(2)(B)(i) of the Act requires 
that we review RVUs no less often than every 5 years. We implemented 
the PFS effective for services furnished beginning January 1, 1992. The 
First Five-Year Review of Work was initiated in December 1994, and was 
effective for services furnished beginning January 1, 1997. The Second 
Five-Year Review of Work was initiated in November 1999, and was 
effective for services furnished beginning January 1, 2002. The Third 
Five-Year Review of Work was initiated in November 2004, and was 
effective for services furnished beginning January 1, 2007. The Fourth 
Five-Year Review of Work, the subject of this proposed notice, was 
initiated in November 2009 and will be effective for services furnished 
beginning January 1, 2012.
    This proposed notice describes the Fourth Five-Year Review of Work 
and sets forth proposed revisions to work RVUs resulting from the 
latest Review. This proposed notice also sets forth corresponding 
proposed changes to PE and malpractice RVUs affecting payment for 
physicians' services. Proposed revisions of physician work RVUs in this 
proposed notice and corresponding proposed changes to the PE and 
malpractice RVUs are subject to a 60-day public comment period. We will 
review public comments, make adjustments to our proposals in response 
to comments, as appropriate, and include final values in the CY 2012 
PFS final rule with comment period, effective for services furnished 
beginning January 1, 2012.
    We note that with each PFS rule, we provide a summary table 
(``Addendum B'') of physician work, PE, and malpractice RVUs by HCPCS 
code for all services under the PFS. For this proposed notice, to 
create Addendum B, we retained the current CY 2011 RVUs for most codes 
and displayed new RVUs for only those codes involved in the Fourth 
Five-Year Review of Work. PE RVUs for these Five-Year Review codes were 
calculated using CY 2009 Medicare PFS utilization data in order to 
maintain consistency with the current CY 2011 RVUs displayed for all 
other services.
    We note that the Addendum B that will appear in the upcoming CY 
2012 PFS proposed rule, where the annual updates to the RVUs and 
revisions to the payment policies under the PFS are customarily 
proposed, will include PE RVUs recalculated using the most recently 
available Medicare PFS utilization data and reflect other changes that 
would result from proposed revisions to PFS payment policies for CY 
2012 that also would be effective beginning January 1, 2012.

C. The Five-Year Review Process

1. Identification of CPT Codes for Review
    We initiated the Fourth Five-Year Review of Work by soliciting 
public comments in the CY 2010 PFS final rule with comment period that 
was published in the Federal Register on November 25, 2009 (74 FR 61738 
and 61941) on potentially misvalued codes for all services. In response 
to our solicitation of potentially misvalued codes, we received 
comments from approximately 16 specialty groups, organizations, and 
individuals involving 113 Current Procedural Terminology (CPT) codes. 
Ten additional codes were submitted by the Medicare contractor medical 
directors (CMDs). Furthermore, CMS identified 96 services that we 
believed should be reviewed as part of the Fourth Five-Year Review of 
Work. These services fall within the two categories described in the CY 
2010 PFS final rule with comment period: (1) Codes that were not 
previously reviewed by the AMA RUC, specifically, Harvard-valued codes 
with an annual utilization of > 30,000 services, and (2) codes that are 
valued as being performed in the inpatient setting, but that are now 
performed predominantly on an outpatient basis (codes with Site-of-
Service anomalies). For Site-of-Service anomaly codes, we also applied 
additional selection criteria. Specifically, the codes we selected for 
the Fourth Five-Year Review of Work contained at least one inpatient 
hospital visit in their value and the most recently available Medicare 
PFS claims data at that time showed annual allowed charges of greater 
than $1 million.
    The following tables list the codes identified for the Fourth Five-
Year Review of Work.
BILLING CODE P

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BILLING CODE P
2. Background on American Medical Association Specialty Society 
Relative Value Update Committee (AMA RUC) Recommendations
    Section 1848(c)(2)(K)(iii) of the Act (as added by section 3134 of 
the Affordable Care Act) specifies that the Secretary may use existing 
processes to receive recommendations on the review and appropriate 
adjustment of potentially misvalued services. In accordance with 
section 1848(c)(2)(K)(iii) of the Act, we develop and propose 
appropriate adjustments to the RVUs, taking into account the 
recommendations provided by the AMA RUC, the Medicare Payment Advisory 
Commission (MedPAC), and others. To respond to concerns expressed by 
MedPAC, the Congress, and other stakeholders regarding the accuracy of 
values for services under the PFS, the AMA RUC has used an annual 
process to systematically identify, review, and provide CMS with 
recommendations for revised work values for many existing potentially 
misvalued services. In addition to providing recommendations to CMS for 
work RVUs, the AMA RUC also reviews direct PE (clinical labor, medical 
supplies, and medical equipment) for individual services and examines 
the many broad methodological issues relating to the development of PE 
RVUs.
    For many years, the AMA RUC has provided CMS with recommendations 
on the appropriate relative values for PFS services. The AMA RUC's 
recommendations on physician work RVUs have resulted in significant 
refinements in physician work RVUs over the years. In recent years CMS 
and the AMA RUC have taken increasingly significant steps to address 
potentially misvalued codes. As MedPAC noted in its March 2009 Report 
to Congress, in the intervening years since MedPAC made the initial 
recommendations, ``CMS and the AMA RUC have taken several steps to 
improve the review process.'' In addition to the Five-Year Reviews of 
Work, over the past several years CMS and the AMA RUC have identified 
and reviewed a number of potentially misvalued codes on an annual basis 
based on various identification screens for codes at risk for being 
misvalued, such as codes with high growth rates, codes that are 
frequently billed together in one encounter, and codes that are valued 
as inpatient services but that are now predominantly performed as 
outpatient services. This annual review of work RVUs and direct PE 
inputs for potentially misvalued codes was further bolstered by the 
Affordable Care Act mandate to examine potentially misvalued codes, 
with an emphasis on the following categories specified in section 
1848(c)(2)(K)(ii) (as added by section 3134 of the Affordable Care 
Act):
     Codes and families of codes for which there has been the 
fastest growth.
     Codes or families of codes that have experienced 
substantial changes in practice expenses.
     Codes that are recently established for new technologies 
or services.
     Multiple codes that are frequently billed in conjunction 
with furnishing a single service.
     Codes with low relative values, particularly those that 
are often billed multiple times for a single treatment.
     Codes which have not been subject to review since the 
implementation of the RBRVS (the `Harvard valued codes').
     Other codes determined to be appropriate by the Secretary. 
(For example, codes for which there have been shifts in the Site-of-
Service (Site-of-Service anomalies), as well as codes that qualify as 
``23-hour stay'' outpatient services.)
    As a result of the annual potentially misvalued code review, CMS 
has reviewed over 700 codes for work and PE RVU changes outside of the 
comprehensive Five-Year Review process over the past several years and 
adopted appropriate work RVUs and direct PE inputs for these services 
in the context of contemporary medical practice.
    This Fourth Five-Year Review of Work advances the progress of our 
initiative to examine potentially misvalued codes by identifying and 
reviewing additional codes for CY 2012 in several of the categories 
specified in the Affordable Care Act, including a number of Harvard-
valued codes. As

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noted previously, we typically discuss the potentially misvalued codes 
initiative in the annual PFS proposed and final rules (for CY 2011, at 
75 FR 40065 through 40082 and 75 FR 73215 through 73216, respectively). 
For example, we provided a detailed discussion of the prior reviews of 
potentially misvalued codes in the CY 2011 PFS final rule with comment 
period (75 FR 73215 through 73216). Furthermore, in addition to the 
proposals in this Five-Year Review of Work proposed notice, we plan to 
continue our work examining potentially misvalued codes for CY 2012 in 
the areas specified by the Affordable Care Act and others identified by 
the Secretary, consistent with the new legislative mandate on this 
issue. We will provide a comprehensive update regarding our progress to 
date in evaluating and revising the values for potentially misvalued 
codes, and discuss our priorities and future plans to ensure the 
accuracy of the relative values for all services paid under the PFS in 
the forthcoming CY 2012 PFS proposed rule.
    We greatly appreciate the considerable sustained efforts made by 
all members and staff of the AMA RUC to date, and we look forward to 
continuing our collaborative work with the AMA RUC toward our mutual 
goal of ensuring that CPT codes are appropriately valued under the PFS.
    For codes used primarily by nonphysician practitioners, the Health 
Care Professionals Advisory Committee (HCPAC), a deliberative body of 
nonphysician practitioners that also convenes during the AMA RUC 
meeting, submits recommendations directly to CMS. The HCPAC represents 
physician assistants, chiropractors, nurses, occupational therapists, 
optometrists, physical therapists, podiatrists, psychologists, 
audiologists, speech pathologists, social workers, and registered 
dieticians. We greatly appreciate the efforts of the HCPAC as well.
3. AMA RUC Five-Year Review of Work Process
    After compiling the list of potentially misvalued codes to be 
reviewed in the Fourth Five-Year Review of Work (Tables 1 through 4), 
we submitted the list to the AMA RUC.
    According to the AMA RUC's Five-Year Review timetable, upon receipt 
of the list of codes from CMS, the AMA RUC sent Level of Interest (LOI) 
forms to all specialty societies and the HCPAC so that the Five-Year 
Review codes could be reviewed initially by the appropriate specialty 
societies. To prepare for presentations of the codes to the AMA RUC, 
most specialty societies compiled data using a standard survey 
instrument whereby respondents compared the surveyed service with 
similar ``reference'' services for which there generally are well-
established work values. Respondents were asked to estimate: the work 
RVU for the survey code; the time to perform the ``pre-'', ``intra-'', 
and ``post-'' service activities; and the technical skill, risk, and 
judgment involved with performing the service. Post-service activities 
were broken down into hospital and office visits and were assigned an 
appropriate evaluation and management (E/M) code by the respondents for 
the typical service. Each specialty society was responsible for 
selecting the physician sample size to be surveyed. In general, a 
minimum of 30 responses was required by the AMA RUC for the survey to 
be considered adequate. It is our understanding that the AMA RUC is 
currently reviewing its survey methodologies in order to improve the 
survey instrument's ability to provide valid and reliable data.
    As part of the AMA RUC's process, the specialty societies also 
provided the AMA RUC with a work RVU recommendation for each code under 
review. The AMA RUC met to hear the presentations from the specialty 
societies for each code, deliberate as a group, and vote on the work 
RVU, physician times, PE direct inputs (if applicable), and other 
aspects pertaining to the valuation of a code. The AMA RUC then sent 
its recommendations to CMS. As we have stated previously in conducting 
Five-Year Reviews, we retain the responsibility for analyzing any 
comments and recommendations received from the AMA RUC, developing the 
proposed notice, evaluating the comments on the proposed notice, and 
deciding whether and how to revise the work RVUs for any given service.

II. CMS Review of Five-Year Review Codes

A. CMS Analytical Approach

    We conducted a clinical review of each code and reviewed the AMA 
RUC recommendations for work RVU, time to perform the ``pre-'', 
``intra-'', and ``post-'' service activities, as well as other 
components of the service which contribute to the value. Our clinical 
review generally includes, but is not limited to, a review of 
information provided by the AMA RUC, medical literature, public 
comments, and comparative databases, as well as a comparison with other 
codes within the Medicare PFS, consultation with other physicians and 
healthcare care professionals within CMS and the Federal Government, 
and the clinical experience of the physicians on the clinical team. We 
also assessed the methodology and data used to develop the 
recommendations and the rationale for the recommendations. As we noted 
in the CY 2011 PFS final rule with comment period (75 FR 73328 through 
73329), the AMA RUC uses a variety of methodologies and approaches to 
assign work RVUs, including building block, survey data, crosswalk to 
key reference or similar codes, and magnitude estimation. The resource-
based relative value system (RBRVS) has incorporated into it cross-
specialty and cross-organ system relativity. This RBRVS requires 
assessment of relative value and takes into account the clinical 
intensity and time required to perform a service. In selecting which 
methodological approach will best determine the appropriate value for a 
service we consider the current physician work and time values, AMA RUC 
recommended physician work and time values, and specialty society 
physician work and time values, as well as the intensity of the 
service, all relative to other services. In general, if we had concerns 
regarding the AMA RUC's application of a particular methodology for a 
code, we assessed whether the recommended work RVUs were appropriate by 
using alternative methodologies. For a full discussion of our views and 
concerns regarding the various methodologies, we refer readers to the 
CY 2011 PFS final rule with comment period (75 FR 73328 through 73329). 
During our clinical review to assess the appropriate values for the 
codes included in the Fourth Five-Year Review, several recurring 
scenarios emerged. We developed systematic approaches to address two 
particular areas of concern.
    The first area of concern pertains to codes with Site-of-Service 
anomalies. These are codes that were originally valued as inpatient 
services but current Medicare PFS claims data show they are furnished 
predominantly as outpatient services. We noted that for nearly all of 
the codes with Site-of-Service anomalies, the accompanying survey data 
suggest they are ``23 hour stay'' outpatient services. We discussed in 
the CY 2011 PFS final rule with comment period (75 FR 73226 through 
73227) the ``23 hour stay service,'' which is a term of art describing 
services that typically have lengthy hospital outpatient recovery 
periods. For these 23 hour stay services, the typical patient is 
commonly at the hospital for less than

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24 hours, but often stays overnight at the hospital. For example, if 
the patient arrives at the hospital at 6 a.m. for a scheduled surgical 
procedure that typically has a lengthy hospital outpatient recovery 
period, the patient may recover during the day and be ready to be 
discharged late in the evening without having to stay overnight at the 
hospital. More commonly, however, if the patient arrives at the 
hospital at noon for a surgical procedure that typically has a lengthy 
hospital outpatient recovery period, the patient may stay at the 
hospital overnight to recover and be discharged the following morning. 
On occasion, the patient may recover at the hospital for longer than a 
single night, either because the patient requires an even longer 
recovery period or the surgery was performed outside of usual business 
hours. For example, if the patient arrives at the hospital at 11 p.m. 
and requires an unscheduled surgical procedure that typically has a 
lengthy hospital outpatient recovery period, the patient may stay at 
the hospital overnight in preparation for surgery, have the surgical 
procedure performed, and then stay through another night recovering at 
the hospital before being discharged. In all these cases, unless a 
treating physician has written an order to admit the patient as an 
inpatient, the patient is considered for Medicare purposes to be a 
hospital outpatient, not an inpatient, and our claims data support that 
the typical 23 hour stay service is billed as an outpatient service.
    We believe that the values of the codes that fall into the 23 hour 
stay category, that is, services that typically have lengthy hospital 
outpatient recovery periods, should not reflect work that is typically 
associated with an inpatient service. For example, inpatient E/M visit 
codes such as CPT codes 99231 (Level 1 subsequent hospital care, per 
day); 99232 (Level 2 subsequent hospital care, per day); and 99233 
(Level 3 subsequent hospital care, per day), should not be included at 
their full RVU value in the valuation of these services that typically 
have lengthy hospital outpatient recovery periods. However, as we 
stated in the CY 2011 PFS final rule with comment period (75 FR 73226 
through 73227), we find it is plausible that while the patient 
receiving the outpatient 23 hour stay service remains a hospital 
outpatient, the patient would typically be cared for by a physician 
during that lengthy recovery period at the hospital. While we do not 
believe that post-procedure hospital visits would be at the inpatient 
level since the typical case is an outpatient who would be ready to be 
discharged from the hospital in 23 hours or less, we believe it is 
generally appropriate to include the intra-service time of the 
inpatient hospital visit in the immediate post-service time of the 23 
hour stay code under review. In addition, we indicated that we believe 
it is appropriate to include a half day, rather than a full day, of a 
discharge day management service. While some commenters advocated for a 
deferral on the issue of valuing 23 hour stay services, we note that a 
number of commenters supported CMS' approach. Consequently, we 
finalized this policy in the CY 2011 PFS final rule with comment period 
(75 FR 73226 through 73227) and encouraged the AMA RUC to apply this 
methodology in developing the recommendations it provides to us for 
valuing 23 hour stay codes, in order to ensure the consistent and 
appropriate valuation of the physician work for these services.
    The AMA RUC reviewed a number of Site-of-Service anomaly codes 
during its February 2011 meeting, many of which are Site-of-Service 
anomaly codes that have been valued on an interim basis since CY 2009. 
These Site-of-Service anomaly codes typically have a lengthy hospital 
outpatient recovery period and thus would be subject to the policy 
previously described for valuing the post-procedure physician care. CMS 
had requested that the AMA RUC re-review them due to concerns over the 
methodology the AMA RUC used originally in valuing these codes (74 FR 
61777 and 75 FR 73221). Contrary to the 23 hour stay policy we 
finalized in the CY 2011 PFS final rule with comment period (75 FR 
73226 through 73227), as described above, in the AMA RUC's review of 
Site-of-Service anomaly codes for CY 2012 as part of this Five-Year 
Review, the AMA RUC often recommended replacing the hospital inpatient 
post-operative visit blocks in the current work values with blocks for 
subsequent observation care services, specifically CPT codes 99224 
(Level 1 subsequent observation care, per day) and 99225 (Level 2 
subsequent observation care, per day), which recently became effective 
under the PFS beginning in CY 2011. The AMA RUC stated in its summary 
recommendations to CMS, ``Adjustments to the allocation of post-
operative visits are used as proxies and do not constitute changes to 
the physician work relative value of the service which was determined 
by magnitude estimation and physician specialty survey data during the 
last RUC review.'' However, we note that the AMA RUC generally 
recommended maintaining the current interim value of the CY 2009 Site-
of-Service anomaly codes while replacing the inpatient hospital visit 
code blocks with subsequent observation care code blocks.
    We continue to be concerned over the AMA RUC's approach to valuing 
the physician work for these Site-of-Service anomaly codes. We believe 
the appropriate methodology entails accounting for the removal of the 
inpatient visit blocks in the work value for the Site-of-Service 
anomaly code since these services are no longer typically furnished in 
the inpatient setting. We do not believe it is appropriate to simply 
exchange the inpatient post-operative visits in the original value with 
subsequent observation care visits (which are appropriately reported in 
cases of nonsurgical hospital outpatient stays spanning 3 calendar days 
or longer), and maintain the current work RVUs. Furthermore, instead of 
the half discharge day management service included in past 
recommendations (CPT code 99238 (Hospital discharge day management; 30 
minutes or less)), the AMA RUC generally recommended including a full 
observation care discharge day management service (CPT code 99217 
(Observation care discharge day management (this code is to be utilized 
by the physician to report all services provided to a patient on 
discharge from ``observation status'' if the discharge is on other than 
the initial date of ``observation status.''))) However, the AMA RUC 
indicated it is currently assessing this code to revise the physician 
times. We do not believe it is appropriate to substitute a full day of 
CPT code 99217 for the half day of CPT code 99238 that would be 
included in the work value for a Site-of-Service anomaly code according 
to CMS' established policy, especially given the AMA RUC's ongoing 
review of CPT code 99217.
    Accordingly, where the data suggested a Site-of-Service anomaly 
code (more than 50 percent of the most recent Medicare utilization is 
outpatient--based on PFS data from the fourth quarter of CY 2009 and 
the first three quarters of CY 2010 to represent the most recent full 
12 months of claims data available) resembles a 23 hour stay outpatient 
service and the AMA RUC's recommended value from the Five-Year Review 
continued to include inpatient visits (or subsequent observation care 
codes) in the post-operative period, we applied the policy described 
above. That is, we consistently removed any post-procedure inpatient 
visits or subsequent observation care services

[[Page 32422]]

included in the AMA RUC-recommended values for these codes and adjusted 
physician times accordingly. We also consistently included the value of 
a half day of a discharge management service.
    An additional concern that arose in our clinical review of the 
codes relates to codes that are typically billed with an E/M service on 
the same day. The AMA RUC noted for a number of codes that the service 
was typically billed with an additional E/M service on the same day; 
however, it appears the AMA RUC did not consistently account for this 
overlap in formulating its time recommendations, an issue discussed on 
a CPT code-specific basis below. In cases where a service is typically 
furnished with an E/M service on the same day, we believe it is 
understood that there may be overlap between the two services in some 
of the activities conducted during the pre- and post-service times of 
the procedure code, and that these overlapping activities should not be 
counted twice. Accordingly, in cases where the most recently available 
Medicare PFS claims data show the code is typically (greater than 50 
percent of the time--based on PFS data from CY 2009) billed with an E/M 
visit on the same day, and where we believe that the AMA RUC did not 
adequately account for overlapping activities in the recommended value 
for the code, we systematically adjusted the physician times for the 
code to account for the overlap. After clinical review of the pre- and 
post-service work, we believe that at least \1/3\ of the physician time 
in both the pre-service evaluation and post-service period is 
duplicative of the E/M visit in this circumstance. Therefore, we 
adjusted the pre-service evaluation portion of the pre-service time to 
\2/3\ of the AMA RUC-recommended time. Similarly, we also adjusted the 
post-service time to \2/3\ of the AMA RUC-recommended time.
    As noted in the CY 2011 proposed rule (75 FR 73328), in reviewing 
the AMA RUC recommendations for valuing the work of new, revised, and 
potentially misvalued services, we expend significant effort in 
evaluating whether the recommended values reflect the work elements, 
such as time, mental effort, and professional judgment, technical skill 
and physical effort, and stress due to risk, involved with furnishing 
the service. Subjecting each of the codes to a clinical review, we 
examined the pre-, post-, and intra-service components of the work. In 
cases where we disagreed with the AMA RUC's recommended work RVU, we 
proposed alternative values based on comparisons with other established 
reference codes with clinical similarity or analogous physician times, 
or the 25th percentile or low value as indicated in the physician 
survey, or, where applicable, employed the building block approach.
    Over the last several years our rate of acceptance of the AMA RUC 
recommendations has been higher. However, in response to concerns 
expressed by MedPAC, and other stakeholders regarding the accurate 
valuation of services under the PFS, we have intensified our scrutiny 
of the work valuations of new, revised, and potentially misvalued 
codes. We note that most recently, section 3134 of the Affordable Care 
Act added a new requirement, which specifies that the Secretary shall 
establish a formal process to validate RVUs under the PFS. The 
validation process may include validation of work elements (such as 
time, mental effort and professional judgment, technical skill and 
physical effort, and stress due to risk) involved with furnishing a 
service and may include validation of the pre-, post-, and intra-
service components of work. Furthermore, the Secretary is directed to 
validate a sampling of the work RVUs of codes identified through any of 
the seven categories of potentially misvalued codes specified by 
section 1848(c)(2)(K)(ii) of the Act (as added by section 3134 of the 
Affordable Care Act). While we are currently in the planning stage of 
developing a formal validation process, we have incorporated, where 
appropriate, the validation principles specified in the law in this 
Five-Year Review process.

B. Summary of Proposed Work RVUs for Five-Year Review Codes

    As stated previously, we sent the AMA RUC an initial list of 219 
codes for review. We have encouraged the AMA RUC to review codes on a 
``family'' basis rather than in isolation in order to ensure that 
appropriate relativity in the system is retained. Consequently, the AMA 
RUC included additional codes for review, resulting in a total of 290 
codes for the Fourth Five-Year Review of Work. Of those 290 codes, 53 
were subsequently sent to the CPT Editorial Panel to consider coding 
changes, 14 were not reviewed by the AMA RUC (and subsequently not 
reviewed by CMS) because the specialty society that had originally 
requested the review in its public comments on the CY 2010 PFS final 
rule with comment period elected to withdraw the codes, 36 were not 
reviewed by the AMA RUC because their values were set as interim final 
in the CY 2011 PFS final rule with comment period, and 14 were not 
reviewed by CMS because they were noncovered services under Medicare. 
Therefore, the AMA RUC reviewed 173 of the 290 codes initially 
identified for this Fourth Five-Year Review of Work, and provided the 
recommendations to CMS that are addressed below in this proposed 
notice. A list of the remaining codes that were identified for possible 
review through the Five-Year Review process but not reviewed can be 
found in section II.E. of this proposed notice. Upon clinical review, 
we are proposing to accept 89 out of 173 (51 percent) of the AMA RUC 
recommendations for work RVUs. In some cases, we also refined physician 
times for codes as deemed appropriate to correspond with the proposed 
work RVUs. CMS' decisions are summarized in Table 6.
    In addition, the HCPAC submitted for CMS review its recommendations 
to modify work RVUs for five CPT codes under the Fourth Five-Year 
Review of Work. Of those five CPT codes, three were not reviewed by CMS 
because the codes were withdrawn by the relevant specialty society due 
to a low survey response rate. We did not accept the HCPAC 
recommendations for the two remaining CPT codes, as detailed in section 
II.D.1 of this proposed notice.
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BILLING CODE C

C. Code-Specific Discussion of Proposed Alternative Work RVUs

1. Drainage of Hematoma
[GRAPHIC] [TIFF OMITTED] TP06JN11.020

    In the Fourth Five-Year Review, we identified CPT codes 10140 and 
10160 as potentially misvalued through the Harvard-Valued--Utilization 
> 30,000 screen.
    For CPT code 10140 (Incision and drainage of hematoma, seroma or 
fluid collection), the AMA RUC reviewed the survey results and 
determined that these data support maintaining the current work RVU of 
1.58 for this service. The AMA RUC believed that the current work RVU 
for CPT code 10140 is appropriate and recommended a work RVU of 1.58.

[[Page 32432]]

    We agree with the AMA RUC-recommended work RVU for CPT code 10140 
and are proposing a work RVU of 1.58 for CY 2012, with a refinement to 
the time. We believe the current pre-service evaluation time of 7 
minutes is more appropriate than the AMA RUC-recommended pre-service 
evaluation time of 17 minutes. CPT code 10160 (Puncture aspiration of 
abscess, hematoma, bulla, or cyst) has the same description of typical 
pre-service evaluation work and an AMA RUC-recommended pre-service 
evaluation time of 7 minutes. After clinical review, we believe that 7 
minutes accurately reflects the time required to conduct the pre-
service evaluation work associated with this service. A complete list 
of CMS time refinements can be found in Table 6.
2. Wound Repair
[GRAPHIC] [TIFF OMITTED] TP06JN11.021

    In the Fourth Five-Year Review, we identified CPT codes 12031, 
12051, and 13101 as potentially misvalued through the Harvard-Valued--
Utilization > 30,000 screen. CPT codes 12032-12047, 12052-12057, and 
13100 were added as part of the family of services for review. In its 
review of this set of CPT codes, the AMA RUC determined that the 
original Harvard values led to compression within these code families, 
which the AMA RUC recommended correcting by reducing the relative 
values for the smallest wound size repair codes and increasing the 
relative values for the larger wound size repair codes.
    In general, the specialty society surveys of physicians furnishing 
these intermediate wound repair codes confirmed that the work of 
performing these services had not changed in the past 5 years and that 
the complexity of patients requiring the services had also remained 
constant. Despite the survey findings, however, the survey median work 
RVUs were usually somewhat higher than the current work RVUs for the 
larger wound size repair codes. For many of these codes, the AMA RUC 
recommended the survey median values as the work RVUs for these wound 
repair services, despite its common recommendation of the survey 25th 
percentile values for codes in other families. In those cases discussed 
below where we disagreed with the AMA RUC recommendations, we based our 
proposed work RVU on the survey 25th percentile value, which was also 
usually higher than the current work RVU for the larger wound size 
repair codes. For the smaller wound size repair codes the AMA RUC 
recommended a lower work RVU than the current work RVU, and we agreed. 
In this way, our proposals for the revised work RVUs for the wound 
repair codes address concerns about compression in the original 
Harvard-valued work RVUs within the family. Our proposed range of work 
RVUs for intermediate wound repair codes in various body areas, while 
not as large as the range that would have resulted from our adoption of 
the AMA RUC's recommendations, nevertheless is greater than the current 
range of work RVUs for the variety of wound sizes described by the 
repair codes.
    For CPT code 12035 (Repair, intermediate, wounds of scalp, axillae, 
trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 
cm), the AMA RUC reviewed the survey data from physicians who 
frequently perform this service and determined that the survey median 
work RVU appropriately accounts for the work required for this service. 
The AMA RUC recommended a work RVU of 3.60 for CPT code 12035.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12035 and believe that the survey 25th percentile value of a work RVU 
of 3.50 is more appropriate for this service. The majority of survey 
respondents

[[Page 32433]]

indicated that the work of performing this service has not changed in 
the past 5 years (79 percent), and that there has been no change in 
complexity among the patients requiring this service (82 percent). We 
believe that the survey 25th percentile value accurately reflects the 
work associated with this service and is consistent with the relativity 
adjustments recommended by the AMA RUC. Therefore, we are proposing an 
alternative work RVU of 3.50 for CPT code 12035 for CY 2012.
    For CPT code 12036 (Repair, intermediate, wounds of scalp, axillae, 
trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 
cm), the AMA RUC reviewed the survey data from physicians who 
frequently perform this service and determined that the survey median 
work RVU appropriately accounts for the work required for this service. 
The AMA RUC recommended a work RVU of 4.50 for CPT code 12036.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12036 and believe that the survey 25th percentile value of a work RVU 
of 4.23 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (81 percent), and that there has been no 
change in complexity among the patients requiring this service (84 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service and is consistent with 
the relativity adjustments recommended by the AMA RUC. We are proposing 
an alternative work RVU of 4.23 for CPT code 12036 for CY 2012.
    In addition to the work RVU adjustment for CPT code 12036, we are 
refining the time associated with this code. We find an intra-service 
time of 70 minutes, the survey median, to be more appropriate than the 
AMA RUC-recommended intra-service time of 75 minutes. Per the survey, 
this time correctly captures the intra-service time differential 
between this CPT code and the key reference code. After clinical 
review, we believe that 70 minutes accurately reflects the time 
required to conduct the intra-service work associated with this 
service. A complete list of CMS time refinements can be found in Table 
6.
    For CPT code 12037 (Repair, intermediate, wounds of scalp, axillae, 
trunk and/or extremities (excluding hands and feet); over 30.0 cm), the 
AMA RUC reviewed the survey data from physicians who frequently perform 
this service and determined that the survey median work RVU 
appropriately accounts for the work required for this service. The AMA 
RUC recommended a work RVU of 5.25 for CPT code 12037.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12037 and believe that the survey 25th percentile value of a work RVU 
of 5.00 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (81 percent), and that there has been no 
change in complexity among the patients requiring this service (83 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service and is consistent with 
the relativity adjustments recommended by the AMA RUC. Therefore, we 
are proposing an alternative work RVU of 5.00 for CPT code 12037 for CY 
2012.
    For CPT code 12045 (Repair, intermediate, wounds of neck, hands, 
feet and/or external genitalia; 12.6 cm to 20.0 cm), the AMA RUC 
reviewed the survey data from physicians who frequently perform this 
service and determined that the survey median work RVU appropriately 
accounts for the physician work required for this service. The AMA RUC 
recommended a work RVU of 3.90 for CPT code 12045.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12045 and believe that the survey 25th percentile value of a work RVU 
of 3.75 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (80 percent), and that there has been no 
change in complexity among the patients requiring this service (80 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service and is consistent with 
the relativity adjustments recommended by the AMA RUC. Therefore, we 
are proposing an alternative work RVU of 3.75 for CPT code 12045 for CY 
2012.
    For CPT code 12046 (Repair, intermediate, wounds of neck, hands, 
feet and/or external genitalia; 20.1 cm to 30.0 cm), the AMA RUC 
reviewed the survey data from physicians who frequently perform this 
service and determined that the survey median work RVU appropriately 
accounts for the work required for this service. The AMA RUC 
recommended a work RVU of 4.60 for CPT code 12046.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12046 and believe that the survey 25th percentile value of a work RVU 
of 4.30 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (79 percent), and that there has been no 
change in complexity among the patients requiring this service (79 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service. Therefore, we are 
proposing an alternative work RVU of 4.30 for CPT code 12046 for CY 
2012.
    In addition to the work RVU adjustment for CPT code 12046, we are 
refining the time associated with this code. This service is typically 
performed on the same day as an E/M visit. We believe some of the 
activities conducted during the pre- and post-service times of the 
procedure code and the E/M visit overlap and, therefore, should not be 
counted twice in developing the procedure's work value. As described in 
section II.A. of this proposed notice, to account for this overlap, we 
reduced the pre-service evaluation and post-service time by one-third. 
We believe that 9 minutes pre-service evaluation time and 9 minutes 
post-service time accurately reflect the time required to conduct the 
work associated with this service. A complete list of CMS time 
refinements can be found in Table 6.
    For CPT code 12047 (Repair, intermediate, wounds of neck, hands, 
feet and/or external genitalia; over 30.0 cm) the AMA RUC reviewed the 
survey data from physicians who frequently perform this service and 
determined the survey median work RVU appropriately accounts for the 
work required for this service. The AMA RUC recommended a work RVU of 
5.50 for CPT code 12046.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12047 and believe that the survey 25th percentile value of a work RVU 
of 4.95 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (79 percent), and that there has been no 
change in complexity among the patients requiring this service (79 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service. Therefore, we are 
proposing an alternative work RVU of 4.95 for CPT code 12047 for CY 
2012.
    In addition to the work RVU adjustment for CPT code 12047, we are 
refining the time associated with this code. Recent Medicare PFS claims 
data show that this service typically is performed on the same day as 
an E/M visit. We believe some of the activities conducted during the 
pre- and post-service times of the procedure code and the E/M visit 
overlap and, therefore,

[[Page 32434]]

should not be counted twice in developing the procedure's work value. 
As described in section II.A. of this proposed notice, to account for 
this overlap, we reduced the pre-service evaluation and post service 
time by one-third. We believe that 9 minutes pre-service evaluation 
time and 10 minutes post-service time accurately reflect the time 
required to conduct the work associated with this service. A complete 
list of CMS time refinements can be found in Table 6.
    For CPT code 12055 (Repair, intermediate, wounds of face, ears, 
eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm), the 
AMA RUC reviewed the survey data from physicians who frequently perform 
this service and determined that the survey median work RVU 
appropriately accounts for the work required to perform this service. 
The AMA RUC recommended a work RVU of 4.65 for CPT code 12055.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12055 and believe that the survey 25th percentile value of a work RVU 
of 4.50 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (79 percent), and that there has been no 
change in complexity among the patients requiring this service (79 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service. Therefore, we are 
proposing an alternative work RVU of 4.50 for CPT code 12055 for CY 
2012.
    In addition to the work RVU adjustment for CPT code 12055, we are 
refining the time associated with this code. We find an intra-service 
time of 60 minutes, the survey median and intra-service time of the key 
reference code, to be more appropriate than the AMA RUC-recommended 
intra-service time of 70 minutes. After clinical review, we believe 
that 60 minutes accurately reflects the time required to conduct the 
intra-service work associated with this service. A complete list of CMS 
time refinements can be found in Table 6.
    For CPT code 12056 (Repair, intermediate, wounds of face, ears, 
eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm), the 
AMA RUC reviewed the survey data from physicians who frequently perform 
this service and determined that the survey median work RVU 
appropriately accounts for the work required to perform this service. 
The AMA RUC recommended a work RVU of 5.50 for CPT code 12056.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12056 and believe that the survey 25th percentile value of a work RVU 
of 5.30 is more appropriate for this service. The majority of survey 
respondents indicated that the work of performing this service has not 
changed in the past 5 years (80 percent), and that there has been no 
change in complexity among the patients requiring this service (81 
percent). We believe that the survey 25th percentile value accurately 
reflects the work associated with this service. Therefore, we are 
proposing an alternative work RVU of 5.30 for CPT code 12056 for CY 
2012.
    In addition to the work RVU adjustment for CPT code 12056, we are 
refining the time associated with this code. We find an intra-service 
time of 70 minutes, the survey median, to be more appropriate than the 
AMA RUC-recommended intra-service time of 85 minutes. After clinical 
review, we believe that 70 minutes accurately reflects the time 
required to conduct the intra-service work associated with this 
service. A complete list of CMS time refinements can be found in Table 
6.
    For CPT code 12057 (Repair, intermediate, wounds of face, ears, 
eyelids, nose, lips and/or mucous membranes; over 30.0 cm), the AMA RUC 
reviewed the survey data from physicians who frequently perform this 
service and determined that the survey median work RVU appropriately 
accounts for the work required to perform this service. The AMA RUC 
recommended a work RVU of 6.28 for CPT code 12057.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
12057 and believe that the survey 25th percentile value of a work RVU 
of 6.00 (the current value) is more appropriate for this service. The 
majority of survey respondents indicated that the work of performing 
this service has not changed in the past 5 years (80 percent), and that 
there has been no change in complexity among the patients requiring 
this service (81 percent). We believe that the survey 25th percentile 
value accurately reflects the work associated with this service. 
Therefore, we are proposing an alternative work RVU of 6.00 for CPT 
code 12057 for CY 2012.
    In addition to the work RVU adjustment for CPT code 12057, we are 
refining the time associated with this code. We find an intra-service 
time of 90 minutes, the survey median, to be more appropriate than the 
AMA RUC-recommended intra-service time of 100 minutes. After clinical 
review, we believe that 90 minutes accurately reflects the time 
required to conduct the intra-service work associated with this 
service. A complete list of CMS time refinements can be found in Table 
6.
    For CPT code 13100 (Repair, complex, trunk; 1.1 cm to 2.5 cm), the 
AMA RUC reviewed the survey data from physicians who frequently perform 
this service and agreed that the current work RVU of 3.17 maintains the 
appropriate relativity for this service. The AMA RUC recommended a work 
RVU of 3.17 for CPT code 13100.
    We note that the AMA RUC reviewed only two CPT codes in the complex 
wound repair family. While at this time we agree with the AMA RUC-
recommended work RVU for CPT code 13100 and are proposing a work RVU of 
3.17 for CY 2012, with a refinement to time, we request that, in order 
to ensure consistency, the AMA RUC review the entire set of codes in 
this family and assess the appropriate gradation of the work RVUs in 
this family. The majority of survey respondents indicated that the work 
of performing this service has not changed in the past 5 years (89 
percent), and that there has been no change in complexity among the 
patients requiring this service (79 percent). We believe at this time 
that the current work RVU (3.17) and current times accurately reflect 
the service.
    For CPT code 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm), the 
AMA RUC reviewed the survey data from physicians who frequently perform 
this service and determined that the current work RVU of 3.96 maintains 
the appropriate relativity for this service. The AMA RUC recommended a 
work RVU of 3.96 for CPT code 13101. As we noted previously for the 
other complex wound code, at this time we agree with the AMA RUC-
recommended work RVU for CPT code 13101 and are proposing a work RVU of 
3.96 for CY 2012, with a refinement to time; however, we request that 
the AMA RUC review the entire set of codes in this family. The majority 
of survey respondents indicated that the work of performing this 
service has not changed in the past 5 years (94 percent), and that 
there has been no change in complexity among the patients requiring 
this service (79 percent). We believe that the current work RVU (3.96) 
and current times accurately reflect the service.
    We are proposing to accept the values for CPT codes 13100 and 13101 
on an interim basis only, as we appreciate that the AMA RUC reviewed 
only two CPT codes in the complex wound repair family. We request that, 
in order to ensure consistency and appropriate gradation in value of 
work, the AMA RUC review all of the codes in this family. Specifically, 
we request that the

[[Page 32435]]

AMA RUC review the remaining codes in the complex wound repair family 
for CY 2013, and we would maintain the values for CPT codes 13100 and 
13101 interim for CY 2012 while the AMA RUC completes its review of 
other codes in the family. For CY 2013, the revised work RVUs for all 
codes examined by the AMA RUC in the complex wound repair family, 
including CPT codes 13100 and 13101, would be included as interim final 
work RVUs in the CY 2013 PFS final rule with comment period, and their 
values would ultimately be finalized for CY 2014.
3. Skin Grafts
[GRAPHIC] [TIFF OMITTED] TP06JN11.022

    In the Fourth Five-Year Review, we identified CPT codes 15120 and 
15732 as potentially misvalued through the Site-of-Service Anomaly 
screen. CPT code 15121 was added as part of the family of services for 
AMA RUC review. In addition, we identified CPT code 15260 as 
potentially misvalued through the Harvard-Valued--Utilization > 30,000 
screen.
    For CPT code 15732 (Muscle, myocutaneous, or fasciocutaneous flap; 
head and neck (e.g., temporalis, masseter muscle, sternocleidomastoid, 
levator scapulae)) the AMA RUC reviewed the survey results from 
physicians who frequently perform this service and recommended that 
this service be valued as a service performed predominately in the 
facility setting, as the survey data indicated that a majority of 
patients have an overnight stay. We note that it is unclear whether 
respondents were offered the option to state that the typical patient 
is in the hospital more than 24 hours, but not admitted as a hospital 
inpatient. The AMA RUC believes that this service should not be 
performed in the outpatient setting and that miscoding is the reason 
the Medicare utilization data reflect outpatient settings as the 
dominant place of service for this code. The AMA RUC and the surveyed 
specialties agreed that additional coding education needs to take 
place.
    The AMA RUC analyzed the survey's estimated physician work and 
agreed that these data support the median work RVU of 19.83, for this 
service, which is slightly less than the current value of 19.90. The 
AMA RUC recommended a work RVU of 19.83 for CPT code 15732.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
15732 and believe that an alternative work RVU of 16.38 is more 
appropriate for this service. We are also refining the time associated 
with this code. Although survey respondents and the AMA RUC indicated 
that patients receiving this service are typically admitted for more 
than 24 hours, the most recent Medicare PFS claims data show that CPT 
code 15732 is a code with a Site-of-Service anomaly. Upon review, it is 
clear that this code is being billed for services furnished to hospital 
outpatients, and we have no reason to believe that miscoding is the 
main reason that outpatient settings are the dominant place of service 
for this code in historical PFS claims data. Therefore, in accordance 
with the policy discussed in section II.A. of this proposed notice, we 
removed the inpatient hospital visit, reduced the discharge day 
management service to one-half, and adjusted times. These adjustments 
resulted in a work RVU of 16.38. We understand the AMA RUC's assertion 
that claims data indicating that this service is performed in an 
outpatient setting is the result of miscoding but, until the claims 
data indicate that this service typically is performed in the inpatient 
setting (greater than 50 percent), we believe it is inappropriate for 
the service to be valued including inpatient E/M building blocks. 
Therefore, we are proposing an alternative work RVU of 16.38 for CPT 
code 15732 for CY 2012, with refinements to the time. We will continue 
to monitor Site-of-Service utilization for this code and may consider 
reviewing the work RVU for this code again in the future if utilization 
patterns change. A complete list of CMS time refinements can be found 
in Table 6.
4. Destruction of Skin Lesions

[[Page 32436]]

[GRAPHIC] [TIFF OMITTED] TP06JN11.023

    In the Fourth Five-Year Review, we identified CPT codes 17271, 
17272 and 17280 as potentially misvalued through the Harvard-Valued--
Utilization > 30,000 screen. The dominant specialty for this family--
dermatology--identified several other codes in the family to be 
reviewed concurrently with these services and submitted to the AMA RUC 
recommendations for CPT codes 17260 through 17286. The AMA RUC 
determined that, with the exception of one CPT code 17284, the survey 
data validated the current values of the destruction of skin lesion 
services. We agreed with this assessment, with a few refinements to 
physician time.
    For CPT code 17270 (Destruction, malignant lesion (e.g., laser 
surgery, electrosurgery, cryosurgery, chemosurgery, surgical 
curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 
cm or less), the AMA RUC reviewed the survey results from physicians 
who frequently perform this service. The AMA RUC noted that the 
specialty did not provide compelling evidence to change the current 
value of the service; therefore, the AMA RUC agreed that the survey 
data support the current value of this service. The AMA RUC recommended 
a work RVU of 1.37 for CPT code 17270.
    As stated above, we agree with the AMA RUC-recommended work RVU for 
CPT code 17270 and are proposing a work RVU of 1.37 for CY 2012, with a 
refinement to the physician time. After clinical review, we believe 
that an intra-service time of 16 minutes, the survey median, accurately 
reflects the time required to conduct the intra-service work associated 
with this service. A complete list of CMS time refinements can be found 
in Table 6.
    For CPT code 17271 (Destruction, malignant lesion (e.g., laser 
surgery, electrosurgery, cryosurgery, chemosurgery, surgical 
curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 
to 1.0 cm) the AMA RUC reviewed the survey results from physicians who 
frequently perform this service. The AMA RUC noted that the specialty 
did not provide compelling evidence to change the current value of the 
service; therefore, the AMA RUC agreed that the survey data support the 
current value of this service. The AMA RUC recommended a work RVU of 
1.54 for CPT code 17271.
    As previously stated, we agree with the AMA RUC-recommended work 
RVU for CPT code 17271 and are proposing a work RVU of 1.54 for CY 
2012, with a refinement to the physician time. After clinical review, 
we believe that 18 minutes, the survey median, accurately reflects the 
time required to conduct the intra-service work associated with this 
service. A complete list of CMS time refinements can be found in Table 
6.
    For CPT code 17274 (Destruction, malignant lesion (e.g., laser 
surgery, electrosurgery, cryosurgery, chemosurgery, surgical 
curettement), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 
to 4.0 cm), the AMA RUC reviewed the survey results from physicians who 
frequently perform this service. The AMA RUC noted that the specialty 
did not provide compelling evidence to change the current value of the 
service; therefore, the AMA RUC agreed that the survey data support the 
current value of this service. The AMA RUC recommended a work RVU of 
2.64 for CPT code 17274.
    As stated above, we agree with the AMA RUC-recommended work RVU for 
CPT code 17274 and are proposing a work RVU of 2.64 for CY 2012, with a 
refinement to the physician time. After clinical review, we believe 
that 33 minutes, the survey median, accurately reflects the time 
required to conduct the intra-service work associated with this 
service. A complete list of CMS time refinements can be found in Table 
6.
5. Partial Mastectomy

[[Page 32437]]

[GRAPHIC] [TIFF OMITTED] TP06JN11.024

    In the Fourth Five-Year Review, we identified CPT code 19302 as 
potentially misvalued through the Site-of-Service Anomaly screen.
    For CPT code 19302 (Mastectomy, partial (e.g., lumpectomy, 
tylectomy, quadrantectomy, segmentectomy); with axillary 
lymphadenectomy), the AMA RUC reviewed the survey results and 
determined that the current work relative value for CPT code 19302 
appropriately places this service relative to other similar services, 
specifically CPT code 38745 (Axillary lymphadenectomy; complete) (work 
RVU = 13.87) which has similar work intensity and time. The AMA RUC 
recommended a work RVU of 13.99 for CPT code 19302.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
19302 and believe that a work RVU of 13.87 is more appropriate for this 
service. After clinical review, we agree with the AMA RUC that CPT code 
19302 is similar in work intensity and time to CPT code 38745 (Axillary 
lymphadenectomy; complete) (work RVU = 13.87), which overlaps 
significantly with CPT code 19302, and as such, we believe these two 
procedures should have the same work RVU. Therefore, we are proposing 
an alternative work RVU of 13.87 for CPT code 19302 for CY 2012.
6. Percutaneous Vertebroplasty/Kyphoplasty
[GRAPHIC] [TIFF OMITTED] TP06JN11.025

    In the Fourth Five-Year Review, we identified CPT codes 22521 as 
potentially misvalued through the Site-of-Service Anomaly screen. CPT 
codes 22520, 22522, 22523, 22524 and 22525 were added as part of the 
family of services for AMA RUC review.
    CPT codes: 22521 (Percutaneous vertebroplasty, 1 vertebral body, 
unilateral or bilateral injection; lumbar); 22523 (Percutaneous 
vertebral augmentation, including cavity creation (fracture reduction 
and bone biopsy included when performed) using mechanical device, 1 
vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); 
thoracic); and 22524 (Percutaneous vertebral augmentation, including 
cavity creation (fracture reduction and bone biopsy included when 
performed) using mechanical device, 1 vertebral body, unilateral or 
bilateral cannulation (eg, kyphoplasty); lumbar) currently include one 
full discharge management day, a CPT code building block usually only 
appropriate for codes that are typically performed in the inpatient 
setting. As these CPT codes are typically performed in the outpatient 
setting, the AMA RUC recommended, and we agree, that the discharge 
management day should be reduced by half. After reviewing the recent 
history of valuing these codes, the AMA RUC asserted that it believes 
that an inadvertent clerical error led to these codes showing one full 
discharge management day in the documentation of their E/M blocks, 
rather than a half day, and that these codes are actually currently 
valued using only half a day block. As such, the AMA RUC concluded that 
the current work RVU for these codes should not be reduced to reflect 
the removal of the half discharge day. The AMA RUC recommended 
maintaining the current work RVU for the 6 CPT codes reviewed in this 
family.
    After reviewing the documentation the AMA RUC provided and CMS 
records from when the codes were last valued, we do not find compelling 
evidence that previously these codes were valued to include only a half 
discharge management day. To the contrary, it appears as though the 
codes were previously surveyed with one full discharge management day. 
According to our established policy, we believe it would be appropriate 
to reduce the work RVU for these codes by the value of the half 
discharge management day and, therefore, we are removing 0.64 of a work 
RVU from each code. Therefore, we are proposing an alternative work RVU 
of 8.01 for CPT code 22521, 8.62 for CPT code 22523, and 8.22 for CPT 
code 22524 for CY 2012.
7. Closed Treatment of Distal Radial Fracture

[[Page 32438]]

[GRAPHIC] [TIFF OMITTED] TP06JN11.026

    In the Fourth Five-Year Review, we identified CPT codes 25600 and 
25605 as potentially misvalued through the Harvard-Valued--Utilization 
> 30,000 screen.
    For CPT code 25600 (Closed treatment of distal radial fracture (eg, 
Colles or Smith type) or epiphyseal separation, includes closed 
treatment of fracture of ulnar styloid, when performed; without 
manipulation), the AMA RUC reviewed the survey results from physicians 
who frequently perform this service. The AMA RUC reviewed the number of 
post-operative visits recommended by the specialties and agreed that 
they were reflective of the service. The AMA RUC believes that the 
survey data support the current value of this service, and recommended 
a work RVU of 2.78 for CPT code 25600.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
25600 and believe that a work RVU of 2.64 is more appropriate for this 
service. We agree with the AMA RUC that CPT code 25600 requires more 
work than key reference CPT code 26600, and find that CPT code 27767 
(Closed treatment of posterior malleolus fracture; without 
manipulation) (work RVU = 2.64) is similar in complexity and intensity 
to CPT code 25600. Therefore, we are proposing an alternative work RVU 
of 2.64 for CPT code 25600 for CY 2012.
    In addition to the work RVU adjustment for CPT code 25600, we are 
refining the time associated with this code. This service typically is 
performed on the same day as an E/M visit. We believe some of the 
activities conducted during the pre- and post-service times of the 
procedure code and the E/M visit overlap and, therefore, should not be 
counted twice in developing the procedure's work value. As described 
earlier, to account for this overlap, we reduced the pre-service 
evaluation and post service time by one-third. We believe that 5 
minutes pre-service evaluation time and 7 minutes post-service time 
accurately reflect the time required to conduct the work associated 
with this service. A complete list of CMS time refinements can be found 
in Table 6.
    For CPT code 25605 (Closed treatment of distal radial fracture 
(e.g., Colles or Smith type) or epiphyseal separation, includes closed 
treatment of fracture of ulnar styloid, when performed; with 
manipulation), the AMA RUC reviewed the survey results from physicians 
who frequently perform this service. The AMA RUC reviewed the number of 
post-operative visits recommended by the specialties and determined 
that they are reflective of the service. Based on comparisons to 
similar codes, the AMA RUC determined that a work RVU of 6.50, the 
survey's 25th percentile, accurately reflects the work required to 
perform this service. The AMA RUC recommended a work RVU of 6.50 for 
CPT code 25605.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
25605 and believe that the survey low value of a work RVU of 6.00 is 
more appropriate for this service. We find CPT code 28113 (Ostectomy, 
complete excision; fifth metatarsal head) (work RVU = 6.11) to be 
similar in intensity and complexity to CPT code 25605, though CPT code 
28113 includes higher intensity office visits than CPT code 25605. 
Therefore, we believe the survey low correctly reflects relativity 
across these services, and are proposing an alternative work RVU of 
6.00 for CPT code 25605 for CY 2012.
    In addition to the work RVU adjustment for CPT code 25605, we are 
refining the time associated with this code. Recent Medicare PFS claims 
data show that this service is typically performed on the same day as 
an E/M visit. We believe some of the activities conducted during the 
pre- and post-service times of the procedure code and the E/M visit 
overlap and, therefore, should not be counted twice in developing the 
procedure's work value. In its time recommendations to us, the AMA RUC 
accounted for duplicate E/M work associated with the pre-service 
period, but not the post-service period. To account for this post-
service overlap, we reduced the post-service time by one-third, a 
methodology described in detail in section II.A. of this proposed 
notice. We believe that 13 minutes post-service time accurately reflect 
the time required to conduct the work associated with this service. A 
complete list of CMS time refinements can be found in Table 6.
8. Orthopaedic Surgery--Thigh/Knee
[GRAPHIC] [TIFF OMITTED] TP06JN11.027

    In the Fourth Five-Year Review, we identified CPT codes 27385 and 
27530 as potentially misvalued through the Site-of-Service Anomaly 
screen.
    For CPT code 27385 (Suture of quadriceps or hamstring muscle 
rupture; primary), the AMA RUC reviewed the survey results from 
physicians who frequently perform this service and determined that 
there was no compelling evidence that the work required to perform this 
service has changed. The AMA RUC recommended that this service be 
valued as a service performed predominately in the facility setting, as 
the survey data indicated that half of patients have an overnight stay. 
The AMA RUC recommended a work RVU of 8.11 for CPT code 27385.
    We disagree with the AMA RUC-recommended work RVU of 8.11 for CPT 
code 27385 and believe that a work RVU of 6.93 is more appropriate for 
this service. We are also refining the time

[[Page 32439]]

associated with this code. We note the data survey indicate that of 
those respondents who stated that they typically perform the procedure 
in the hospital, 19 percent (6 out of 32) stated that the patient is 
``discharged the same day,'' 31 percent (10 out of 32) stated the 
patient is ``kept overnight (less than 24 hours),'' and 50 percent (16 
out of 32) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As indicated by the most recent Medicare PFS claims data, CPT 
code 27385 is a code with a Site-of-Service anomaly since more than 50 
percent of the Medicare utilization is not inpatient. Therefore, in 
accordance with the policy discussed in section II.A. of this proposed 
notice, we removed the hospital visit, reduced the discharge day 
management service to one-half, and adjusted times. As a result, we are 
proposing an alternative work RVU of 6.93 with refinements to the time 
for CPT code 27385 for CY 2012. A complete list of CMS time refinements 
can be found in Table 6.
    For CPT code 27530 (Closed treatment of tibial fracture, proximal 
(plateau); without manipulation), the AMA RUC reviewed the survey 
responses from 33 (of 200 surveyed) physicians. Based on comparisons to 
reference codes, the AMA RUC recommended a work RVU of 2.81 for CPT 
code 27530.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
27530 and believe that a work RVU of 2.65 is more appropriate for this 
service. We are also refining the time associated with this code. 
Recent Medicare PFS claims data show that this service is typically 
performed on the same day as an E/M visit. We believe some of the 
activities conducted during the pre- and post-service times of the 
procedure code and the E/M visit overlap and, therefore, should not be 
counted twice in developing the procedure's work value. As described 
earlier in section II.A. of this proposed notice, to account for this 
overlap, we reduced the pre-service evaluation and post-service time by 
one-third. We believe that 5 minutes pre-service evaluation time and 7 
minutes post-service time accurately reflect the time required to 
conduct the work associated with this service. We also removed the 2 
minutes of pre-service positioning time, as it does not appear from the 
vignette that positioning is required for a non-manipulated extremity.
    In order to determine the appropriate work RVU for this service 
given the time changes, we calculated the value of the extracted time 
and subtracted it from the AMA RUC-recommended work RVU. For CPT code 
27530, we removed a total of 7 minutes from the AMA RUC-recommended 
pre- and post-service time, which amounts to the removal of 0.16 of a 
work RVU. Therefore, we are proposing an alternative work RVU of 2.65 
with refinement in time for CPT code 27530 for CY 2012. A complete list 
of CMS time refinements can be found in Table 6. Additionally, we 
recommend that the AMA RUC examine all of the non-manipulation fracture 
codes to determine if positioning time was incorporated into the work 
RVU for the codes and, if so, whether the need for positioning time was 
documented.
9. Treatment of Ankle Fracture
[GRAPHIC] [TIFF OMITTED] TP06JN11.028

    In the Fourth Five-Year Review, we identified CPT code 27792 (Open 
treatment of distal fibular fracture (lateral malleolus), includes 
internal fixation, when performed) as potentially misvalued through the 
Site-of-Service Anomaly screen. For CPT code 27792, the AMA RUC used 
magnitude estimation and recommended that the current value of this 
service, 9.71 RVUs, be maintained, and replaced the current inpatient 
hospital E/M visit block with a subsequent observation care service 
while maintaining a full discharge day management service.
    We disagree with the AMA RUC-recommended work RVU of 9.71 for CPT 
code 27792. The AMA RUC indicated in its summary of recommendations 
that the survey data show 100 percent (53 out of 53) of survey 
respondents stated they perform the procedure ``in the hospital.'' Of 
those respondents who stated that they typically perform the procedure 
in the hospital, 42 percent (22 out of 53) stated that the patient is 
``discharged the same day,'' 44 percent (23 out of 53) stated the 
patient is ``kept overnight (less than 24 hours),'' and 13 percent (7 
out of 53) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As indicated by the most recent Medicare PFS claims data, CPT 
code 27792 is a code with a Site-of-Service anomaly. Therefore, in 
accordance with the policy discussed in section II.A. of this proposed 
notice, we removed the subsequent observation care service, reduced the 
discharge day management service to one-half, and adjusted times. As a 
result, we are proposing an alternative work RVU of 8.75 with 
refinements to the time for CPT code 27792 for CY 2012. A complete list 
of CMS time refinements can be found in Table 6.
10. Orthopaedic Surgery/Podiatry

[[Page 32440]]

[GRAPHIC] [TIFF OMITTED] TP06JN11.029

    In the Fourth Five-Year Review, we identified CPT codes 28002, 
28120, 28122, 28715, 28820, and 28825 as potentially misvalued through 
the Site-of-Service Anomaly screen. CPT code 28003 was added as part of 
the family of services for AMA RUC review. CMS also identified CPT code 
28285 as potentially misvalued through the Harvard-Valued--Utilization 
> 30,000 screen.
    For CPT code 28002 (Incision and drainage below fascia, with or 
without tendon sheath involvement, foot; single bursal space), the AMA 
RUC reviewed the survey responses and determined that CPT code 28002 
should be decreased to the survey 25th percentile work RVU. The AMA RUC 
recommended a work RVU of 5.34 for CPT code 28002.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
28002 and believe that the survey low value of a work RVU of 4.00 is 
more appropriate for this service. We find CPT code 28002 to be closer 
to the complexity and intensity of CPT code 58353 (Endometrial 
ablation, thermal, without hysteroscopic guidance) (work RVU = 3.60) 
which has similar times and lower-level visits to CPT code 28002. We 
believe that the survey low value accurately reflects the work 
associated with this service and are proposing an alternative work RVU 
of 4.00 for CPT code 28002 for CY 2012.
    For CPT code 28120 (Partial excision (craterization, saucerization, 
sequestrectomy, or diaphysectomy) bone (e.g., osteomyelitis or 
bossing); talus or calcaneus), the AMA RUC used magnitude estimation, 
recommended that the current work RVU of 8.27 for this service be 
maintained, and replaced the current inpatient hospital E/M visit block 
with a subsequent observation care service while maintaining a full 
discharge day management service.
    We disagree with the AMA RUC-recommended work RVU of 8.27 for CPT 
code 28120. The AMA RUC indicated in its summary of recommendations 
that the survey data show 87 percent (45 out of 52) of survey 
respondents stated they perform the procedure ``in the hospital.'' Of 
those respondents who stated that they typically perform the procedure 
in the hospital, 16 percent (7 out of 45) stated that the patient is 
``discharged the same day,'' 18 percent (8 out of 45) stated the 
patient is ``kept overnight (less than 24 hours),'' and 67 percent (30 
out of 45) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As indicated by the most recent Medicare PFS claims data, CPT 
code 28120 is a code with a Site-of-Service anomaly. Therefore, in 
accordance with the policy discussed in section II.A. of this proposed 
notice, we removed the subsequent observation care service, reduced the 
discharge day management service to one-half, and adjusted times. As a 
result, we are proposing an alternative work RVU of 7.31 with 
refinements to the time for CPT code 28120 for CY 2012. A complete list 
of CMS time refinements can be found in Table 6.
    For CPT code 28122 (Partial excision (craterization, saucerization, 
sequestrectomy, or diaphysectomy) bone (e.g., osteomyelitis or 
bossing); tarsal or metatarsal bone, except talus or calcaneus), the 
AMA RUC used magnitude estimation, recommended that the current work 
RVU of 7.56 for this service should be maintained for CY 2012, and 
replaced the current inpatient hospital E/M visit block with a 
subsequent observation care service while maintaining a full discharge 
day management service.
    We disagree with the AMA RUC-recommended work RVU of 7.56 for CPT 
code 28122. The AMA RUC indicated in its summary of recommendations 
that the survey data show 83 percent (43 out of 52) of survey 
respondents stated they perform the procedure ``in the hospital.'' Of 
those respondents who stated that they typically perform the procedure 
in the hospital, 12 percent (5 out of 43) stated that the patient is 
``discharged the same day,'' 30 percent (13 out of 43) stated the 
patient is ``kept overnight (less than 24 hours),'' and 58 percent (23 
out of 43) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As indicated by the most recent Medicare PFS claims data, CPT 
code 28122 is a code with a Site-of-Service anomaly. Therefore, in 
accordance with the policy discussed in section II.A. of this proposed 
notice, we removed the subsequent observation care service, reduced the 
discharge day management service to one-half, and adjusted times. As a 
result, we are proposing an alternative work RVU of 6.76 with 
refinements to the time for CPT code 28122 for CY 2012. A complete list 
of CMS time refinements can be found in Table 6.
    For CPT code 28285 (Correction, hammertoe (e.g., interphalangeal 
fusion, partial or total phalangectomy)), the AMA RUC reviewed the 
survey responses and agreed that the appropriate work RVU for CPT code 
28285 is a work RVU of 5.62, crosswalked from CPT code 28675. The AMA 
RUC recommended a work RVU of 5.62 for CPT code 28285.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
28285 and believe that a work RVU of 4.76, the current work RVU, is 
more appropriate for this service. The majority of survey respondents 
indicated that the work of performing this service has not changed in 
the past 5 years (67 percent), and that there has been no change in 
complexity among

[[Page 32441]]

the patients requiring this service (81 percent). We believe that the 
current work RVU accurately reflects the work associated with this 
service. Therefore, we are proposing an alternative work RVU of 4.76 
for CPT code 28675 for CY 2012.
    For CPT code 28715 (Arthrodesis; triple), the AMA RUC reviewed the 
survey responses from 30 (of 150 surveyed) physicians for CPT code 
28715 and determined that the current work RVU of 14.60 maintains the 
correct relativity among similar services. The AMA RUC recommended that 
this service be valued as a service performed predominately in the 
facility setting. The AMA RUC indicated that since the typical patient 
is kept overnight, the AMA RUC believes that one inpatient hospital 
visit as well as one discharge day management service should be 
maintained in the post-operative visits for this service.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
28715 and believe that a work RVU of 13.42 is more appropriate for this 
service. While the survey data show 93 percent (28 out of 30) of survey 
respondents stated they perform the procedure ``in the hospital,'' of 
those respondents who stated that they typically perform the procedure 
in the hospital, 7 percent (2 out of 28) stated that the patient is 
``discharged the same day,'' 32 percent (9 out of 28) stated the 
patient is ``kept overnight (less than 24 hours),'' and 61 percent (17 
out of 28) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As indicated by the most recent Medicare PFS claims data, CPT 
code 28715 is a code with a Site-of-Service anomaly. Therefore, in 
accordance with the policy discussed in section II.A. of this proposed 
notice, we removed the inpatient hospital visit, reduced the discharge 
day management service to one-half, and adjusted times. As a result, we 
are proposing an alternative work RVU of 13.42 with refinements to the 
time for CPT code 28715 for CY 2012. A complete list of CMS time 
refinements can be found in Table 6.
    For CPT code 28820 (Amputation, toe; metatarsophalangeal joint), 
the AMA RUC reviewed the survey responses and determined that the 
survey median work RVU of 7.00 appropriately reflects the physician 
work required to perform this service and maintains relativity among 
similar services. Therefore, the AMA RUC recommended a work RVU of 7.00 
for CPT code 28820. In its recommendation to us for CPT code 28820, the 
AMA RUC included one post-operative hospital visit and one full 
discharge management day.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
28820 and believe that a work RVU of 5.82 is more appropriate for this 
service. The survey data for this code show that 87 percent of 
respondents indicated that they perform this procedure in the hospital, 
but without a distinction between the patient's status as a hospital 
inpatient or outpatient. Recent Medicare PFS claims data indicate that 
this service is typically (greater than 50 percent) performed in the 
outpatient setting. As we discussed in section II.A. of this proposed 
notice, for codes with Site-of-Service anomalies where the service is 
typically performed in the outpatient setting but valued with inpatient 
inputs, our policy is to remove any post-procedure inpatient visits 
remaining in the values for the codes, and adjust the physician times 
and work RVU accordingly. Therefore, in accordance with this policy, we 
reduced the discharge management day to half a day, eliminated the 
post-operative hospital visit, and adjusted the time and work RVU 
accordingly. As a result, we are proposing an alternative work RVU of 
5.82 with refinements to the time for CPT code 28820 for CY 2012. A 
complete list of CMS time refinements can be found in Table 6.
    For CPT code 28825 (Amputation, toe; interphalangeal joint), the 
AMA RUC used magnitude estimation and ultimately recommended 
maintaining the current work RVU of 6.01, while also maintaining a full 
discharge day management service.
    We disagree with the AMA RUC-recommended work RVU of 6.01 for CPT 
code 28825. The AMA RUC indicated in its summary of recommendations 
that the survey data show 84 percent (37 out of 44) of survey 
respondents stated they perform the procedure ``in the hospital.'' Of 
those respondents who stated that they typically perform the procedure 
in the hospital, 36 percent (13 out of 37) stated that the patient is 
``discharged the same day,'' 11 percent (4 out of 37) stated the 
patient is ``kept overnight (less than 24 hours),'' and 52 percent (19 
out of 37) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As indicated by the most recent Medicare PFS claims data, CPT 
code 28825 is a code with a Site-of-Service anomaly. Therefore, in 
accordance with the policy discussed in section II.A. of this proposed 
notice, we reduced the discharge day management service to one-half, 
and adjusted times. As a result, we are proposing an alternative work 
RVU of 5.37 with refinements to the time for CPT code 28825 for CY 
2012. A complete list of CMS time refinements can be found in Table 6.
11. Application of Cast and Strapping
[GRAPHIC] [TIFF OMITTED] TP06JN11.030

    In the Fourth Five-Year Review, we identified CPT codes 29125, 
29405 and 29515 as potentially misvalued through the Harvard-Valued--
Utilization > 30,000 screen. CPT codes 29126 and 29425 were added as 
part of the family of services for AMA RUC review.
    For CPT code 29125 (Application of short arm splint (forearm to 
hand); static), the AMA RUC reviewed the survey results and determined 
that these

[[Page 32442]]

data support maintaining the current work RVU of 0.59 for this service. 
The AMA RUC recommended a work RVU of 0.59 for CPT code 29125. In its 
recommendation to us, the AMA RUC also noted that there is typically an 
E/M service furnished on the same day as this service.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
29125 and believe that a work RVU of 0.50 is more appropriate for this 
service. We are also refining the time associated with this code. 
Recent Medicare PFS claims data affirm that this service is typically 
performed on the same day as an E/M visit. We believe some of the 
activities conducted during the pre- and post-service times of the 
procedure code and the E/M visit overlap and, therefore, should not be 
counted twice in developing the procedure's work value. As described 
earlier in section II.A. of this proposed notice, to account for this 
overlap, we reduced the pre-service evaluation and post-service time by 
one-third. We believe that 5 minutes pre-service evaluation time and 3 
minutes post-service time accurately reflect the time required to 
conduct the work associated with this service as described by the CPT 
code-associated specialties to the AMA RUC.
    In order to determine the appropriate work RVU for this service 
given the time changes, we calculated the value of the extracted time 
and subtracted it from the AMA RUC-recommended work RVU. For CPT code 
29125, we removed a total of 4 minutes from the AMA RUC-recommended 
pre- and post-service time, which amounts to the removal of 0.09 of a 
work RVU. Therefore, we are proposing an alternative work RVU of 0.50 
with refinement in time for CPT code 29125 for CY 2012. A complete list 
of CMS time refinements can be found in Table 6.
    For CPT code 29126 (Application of short arm splint (forearm to 
hand); dynamic), the AMA RUC reviewed the survey results and determined 
that the median work RVU overestimates the work value for this service 
and that there is no compelling evidence that the physician work has 
recently changed. Therefore, the AMA RUC recommended maintaining the 
current work RVU of 0.77 for CPT code 29126. In its recommendation to 
us, the AMA RUC noted that there is typically an E/M service furnished 
on the same day as this service.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
29126 and believe that a work RVU of 0.68 is more appropriate for this 
service. We are also refining the time associated with this code. 
Recent Medicare PFS claims data affirm that this service is typically 
performed on the same day as an E/M visit. We believe some of the 
activities conducted during the pre- and post-service times of the 
procedure code and the E/M visit overlap and, therefore, should not be 
counted twice in developing the procedure's work value. As described 
earlier in section II.A. of this proposed notice, to account for this 
overlap, we reduced the pre-service evaluation and post-service time by 
one-third. We believe that 5 minutes pre-service evaluation time and 3 
minutes post-service time accurately reflect the time required to 
conduct the work associated with this service as described by the CPT 
code-associated specialties to the AMA RUC.
    In order to determine the appropriate work RVU for this service 
given the time changes, we calculated the value of the extracted time 
and subtracted it from the AMA RUC-recommended work RVU. For CPT code 
29126, we removed a total of 4 minutes from the AMA RUC-recommended 
pre- and post-service time, which amounts to the removal of 0.09 of a 
work RVU. Therefore, we are proposing an alternative work RVU of 0.68 
with refinement in time for CPT code 29126 for CY 2012. A complete list 
of CMS time refinements can be found in Table 6.
    For CPT code 29515 (Application of short leg splint (calf to 
foot)), the AMA RUC reviewed the survey results and determined that 
these data support maintaining the current work RVU of 0.73 for this 
service. The AMA RUC recommended a work RVU of 0.73 for CPT code 29515. 
In its recommendation to us, the AMA RUC noted that there is typically 
an E/M service furnished on the same day as this service.
    We agree with the AMA RUC-recommended work RVU of 0.73 for CPT code 
29515, with a refinement to time. Recent Medicare PFS claims data 
affirm that this service is typically performed on the same day as an 
E/M visit. We believe some of the activities conducted during the pre- 
and post-service times of the procedure code and the E/M visit overlap 
and, therefore, should not be counted twice in developing the 
procedure's work value. As described earlier in section II.A. of this 
proposed notice, to account for this overlap, we reduced the pre-
service evaluation and post-service time by one-third. We believe that 
5 minutes pre-service evaluation time and 3 minutes post-service time 
accurately reflect the time required to conduct the work associated 
with this service as described by the CPT code-associated specialties 
to the AMA RUC. Despite this reduction in time, after clinical review 
we believe that the AMA RUC-recommended work RVU of 0.73 accurately 
reflects the work associated with this service and maintains 
appropriate relativity with similar services. Therefore, we are 
proposing a work RVU of 0.73 for CY 2012, with a refinement to the 
time.
12. Cardiothoracic Surgery

[[Page 32443]]

[GRAPHIC] [TIFF OMITTED] TP06JN11.031

    In the Fourth Five-Year Review, we identified CPT code 33411 
(Replacement, aortic valve; with aortic annulus enlargement, 
noncoronary sinus) as potentially misvalued through the Site-of-Service 
Anomaly screen. We included a number of services that were also 
identified by the Society of Thoracic Surgeons (STS) in their public 
comments regarding candidate services for the Fourth Five-Year Review, 
including ventricular assist device (VAD) removal codes, VAD insertion 
and replacement codes, lung transplant codes, pulmonary artery 
embolectomy codes, descending thoracic aorta repair codes, congenital 
cardiac codes and general thoracic surgery CPT code 43415 (Suture of 
esophageal wound or injury; transthoracic or transabdominal approach). 
In its review of these cardiothoracic surgery codes, the AMA RUC 
recommended increasing the work RVUs for most of the codes (often 
substantially), while recommending that many of the service times be 
reduced. We also note that many of these codes have had the same work 
value since 1993, potentially historically supporting the longstanding 
appropriateness of the value from the perspective of interested 
specialties. While we discuss the proposed values for each revised code 
below, we note that for most of the codes in this family (but not all) 
we agreed with the AMA RUC that the work RVU should be increased, but 
believe that the survey 25th percentile work RVU reflected a clinically 
more appropriate increase than the work RVU recommended by the AMA RUC.
    Additionally, the AMA RUC recommended global period changes for 
several codes in the category of cardiothoracic surgery. For CY 2012, 
we

[[Page 32444]]

agree with the AMA RUC-recommended global period changes and work RVUs 
and are proposing the following: For CPT code 33977 (Removal of 
ventricular assist device; extracorporeal, single ventricle), a 
proposed work RVU of 20.86 and global period change from 090 to XXX (a 
global period of XXX means the concept does not apply); for CPT code 
33978 (Removal of ventricular assist device; extracorporeal, 
biventricular), a proposed work RVU of 25 and global period change from 
090 to XXX; for CPT code 36200 (Introduction of catheter, aorta), a 
proposed work RVU of 3.02 and global period change from XXX to 000; for 
CPT code 36246 (Selective catheter placement, arterial system; initial 
second order abdominal, pelvic, or lower extremity artery branch, 
within a vascular family), a proposed work RVU of 5.27 and a global 
period change from XXX to 000; and for CPT code 36821 (Arteriovenous 
anastomosis, open; direct, any site (eg, cimino type) (separate 
procedure)), a proposed work RVU of 12.11 and a global period change 
from XXX to 000.
    For CPT code 32851 (Lung transplant, single; without 
cardiopulmonary bypass), the AMA RUC reviewed the survey responses and 
determined that the survey 25th percentile work RVU of 63.00 
appropriately accounts for the physician work required to perform this 
service.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
32851 and believe that a work RVU of 59.64 is more appropriate for this 
service. Comparing CPT code 33255 (Operative tissue ablation and 
reconstruction of atria, extensive (eg, maze procedure); without 
cardiopulmonary bypass) (work RVU = 29.04) with CPT code 33256 
(Operative tissue ablation and reconstruction of atria, extensive 
(e.g., maze procedure); with cardiopulmonary bypass) (work RVU = 
34.90), there is a difference in work RVU of 5.86. This difference in 
work RVUs reflects the additional time and physician work performed 
while the patient is on cardiopulmonary bypass. We believe that this is 
the appropriate interval in physician work distinguishing CPT code 
32852 (Lung transplant, single; with cardiopulmonary bypass), from CPT 
code 32851 (Lung transplant, single; without cardiopulmonary bypass). 
As we are proposing a work RVU of 65.05 for CPT code 32852 (see below), 
we believe a work RVU of 59.64 accurately reflects the work associated 
with CPT code 32851 and maintains appropriate relativity among similar 
services. Therefore, we are proposing an alternative work RVU of 59.64 
for CPT code 32851 for CY 2012.
    For CPT code 32852 (Lung transplant, single; with cardiopulmonary 
bypass), the AMA RUC reviewed the survey responses and determined that 
the survey 25th percentile work RVU was too low and the median work RVU 
was too high. Therefore, the AMA RUC recommended a work RVU of 74.37 
for CPT code 32582.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
32582 and believe that the survey 25th percentile value of a work RVU 
of 65.50 is more appropriate for this service. Therefore, we are 
proposing an alternative work RVU of 65.50 for CPT code 32582 for CY 
2012.
    For CPT code 32853 (Lung transplant, double (bilateral sequential 
or en bloc); without cardiopulmonary bypass), the AMA RUC reviewed the 
survey responses and determined that the survey median work RVU of 
90.00 appropriately accounts for the physician work required to perform 
this service.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
32853 and believe that the survey 25th percentile value of 84.48 is 
more appropriate for this service as a reflection of the time and 
intensity of the service in relation to other major surgical 
procedures. Therefore, we are proposing an alternative work RVU of 
84.48 for CPT code 32853 for CY 2012.
    For CPT code 32854 (Lung transplant, double (bilateral sequential 
or en bloc); with cardiopulmonary bypass), the AMA RUC reviewed the 
survey responses and determined that the survey median work RVU of 
95.00 appropriately accounts for the physician work required to perform 
this service.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
32854 and believe that the survey 25th percentile value of 90.00 is 
more appropriate for this service. A work RVU of 90.00 maintains the 
relativity between CPT code 32851 (Lung transplant, single; without 
cardiopulmonary bypass) and CPT code 32854, which describes a double 
lung transplant. We believe this work RVU reflects the increased 
intensity in total service for CPT code 32584 when compared to CPT code 
32851. Therefore, we are proposing an alternative work RVU of 90.00 for 
CPT code 32854 for CY 2012.
    For CPT code 33030 (Pericardiectomy, subtotal or complete; without 
cardiopulmonary bypass), the AMA RUC reviewed the survey responses and 
determined that the survey median work RVU of 39.50 for CPT code 33030 
appropriately accounts for the work required to perform this service.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
33030 and believe that the survey 25th percentile value of 36.00 is 
more appropriate for this service. Therefore, we are proposing an 
alternative work RVU of 36.00 for CPT code 33030 for CY 2012.
    For CPT code 33120 (Excision of intracardiac tumor, resection with 
cardiopulmonary bypass), the AMA RUC reviewed the survey responses and 
determined that the 25th percentile work RVU for CPT code 33120 
appropriately accounts for the work required to perform this service. 
The AMA RUC recommended a work RVU of 42.88 for CPT code 33120.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
33120 and believe that a work RVU of 38.45 is more appropriate for this 
service. We compared CPT code 33120 with CPT code 33677 (Closure of 
multiple ventricular septal defects; with removal of pulmonary artery 
band, with or without gusset) (work RVU = 38.45) and found the codes to 
be the similar in complexity and intensity. We believe that a work RVU 
of 38.45 accurately reflects the work associated with CPT code 33677 
and properly maintains the relativity of similar service. Therefore, we 
are proposing an alternative work RVU of 38.45 for CPT code 33120 for 
CY 2012.
    For CPT code 33412 (Replacement, aortic valve; with 
transventricular aortic annulus enlargement (Konno procedure)), the AMA 
RUC reviewed the survey responses and determined that the survey median 
work RVU for CPT code 33412 appropriately accounts for the work 
required to perform this service. The AMA RUC recommended a work RVU of 
60.00 for CPT code 33412.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
33412 and believe that the survey 25th percentile value of 59.00 is 
more appropriate for this service. Therefore, we are proposing an 
alternative work RVU of 59.00 for CPT code 33412 for CY 2012.
    For CPT code 33468 (Tricuspid valve repositioning and plication for 
Ebstein anomaly), the AMA RUC reviewed the survey responses and 
determined that the survey median work RVU for CPT code 33468 
appropriately accounts for the work required to perform this service. 
The AMA RUC recommended a work RVU of 50.00 for CPT code 33468.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
33468 and believe that the survey 25th percentile value of 45.13 is 
more

[[Page 32445]]

appropriate for this service. Therefore, we are proposing an 
alternative work RVU of 45.13 for CPT code 33468 for CY 2012.
    For CPT code 33645 (Direct or patch closure, sinus venosus, with or 
without anomalous pulmonary venous drainage), the AMA RUC reviewed 
survey responses and determined that the survey median work RVU for CPT 
code 33645 appropriately accounts for the work required to perform this 
service. The AMA RUC recommended a work RVU of 33.00 for CPT code 
33645.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
33645 and believe that the survey 25th percentile value of 31.30 
appropriately captures the total work for the service. Therefore, we 
are proposing an alternative work RVU of 31.30 for CPT code 33645 for 
CY 2012.
    For CPT code 33647 (Repair of atrial septal defect and ventricular 
septal defect, with direct or patch closure), the AMA RUC reviewed 
survey responses and determined that the survey median work RVU for CPT 
code 33467 appropriately accounts for the work required to perform this 
service. The AMA RUC recommended a work RVU of 35.00 for CPT code 
33647.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
33647 and believe that the survey 25th percentile value of 33.00 is 
more appropriate for this service. Therefore, we are proposing an 
alternative work RVU of 33.00 for CPT code 33647 for CY 2012.
    For CPT code 33692 (Complete repair tetralogy of Fallot without 
pulmonary atresia), the AMA RUC reviewed survey responses, determined 
that the survey median work RVU for CPT code 33692 appropriately 
accounts for the work, and recommended a median work RVU of 38.75 for 
CPT code 33692.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
33692 and believe that the survey 25th percentile value of 36.15 is 
more appropriate for this service. Therefore, we are proposing an 
alternative work RVU of 36.15 for CPT code 33692 for CY 2012.
    For CPT code 33710 (Repair sinus of Valsalva fistula, with 
cardiopulmonary bypass; with repair of ventricular septal defect), the 
AMA RUC reviewed survey response, determined that the survey median 
work RVU for CPT code 33710 appropriately accounts for the work 
required to perform this service, and recommended a work RVU of 43.00 
for CPT code 33710.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
33710 and believe that the survey 25th percentile value of 37.50 is 
more appropriate for this service. We believe the physician time and 
intensity for CPT code 33710 reflects the appropriate incremental 
adjustment when compared to the reference service, CPT code 33405. 
Therefore, we are proposing an alternative work RVU of 37.50 for CPT 
code 33710 for CY 2012.
    For CPT code 33875 (Descending thoracic aorta graft, with or 
without bypass), the AMA RUC reviewed survey responses and determined 
that the 25th percentile work RVU for code 33875 appropriately accounts 
for the work required to perform this service. The AMA RUC recommended 
a work RVU of 56.83 for CPT code 33875.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
33875 and believe that a work RVU of 50.72 is more appropriate for this 
service. We compared CPT code 33875 with CPT code 33465 (Replacement, 
tricuspid valve, with cardiopulmonary bypass) (work RVU = 50.72) and 
believe that CPT code 33875 is similar to CPT code 33465, with similar 
inpatient and outpatient work. We believe this work RVU corresponds 
better to the value of the service than the survey 25th percentile work 
RVU. Therefore, we are proposing an alternative work RVU of 50.72 for 
CPT code 33875 for CY 2012.
    For CPT code 33910 (Pulmonary artery embolectomy; with 
cardiopulmonary bypass), the AMA RUC reviewed survey responses. After 
reviewing the service, the AMA RUC determined that it met the 
compelling evidence guidelines. The AMA RUC recommended a work RVU of 
52.33 for CPT code 33910.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
33910 and believe that a work RVU of 48.21 is more appropriate for this 
service. We compared CPT code 33910 with CPT code 33542 (Myocardial 
resection (eg, ventricular aneurysmectomy)) (work RVU = 48.21), and we 
recognize that CPT code 33542 is not an emergency service. 
Nevertheless, this procedure requires cardiopulmonary bypass and has 
physician time and visits that are similar to CPT code 33910 and that 
are consistently necessary for the care required for the patient. We 
believe that a work RVU of 48.21 accurately reflects the work 
associated with CPT code 33910 and properly maintains the relativity 
for a similar service. Therefore, we are proposing an alternative work 
RVU of 48.21 for CPT code 33910 for CY 2012.
    For CPT code 33935 (Heart-lung transplant with recipient 
cardiectomy-pneumonectomy), the AMA RUC reviewed survey responses, 
determined that the survey median work RVU appropriately accounts for 
the physician work required to perform this service, and recommended a 
work RVU of 100.00 for CPT code 33935.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
33935 and believe that the survey 25th percentile value of 91.78 is 
more appropriate for this service. We believe this service is more 
intense and complex than CPT code 33945 and that the survey 25th 
percentile work RVU accurately reflects the increased intensity and 
complexity when compared to the reference CPT code 33945. Therefore, we 
are proposing an alternative work RVU of 91.78 for CPT code 33935 for 
CY 2012.
    For CPT code 33980 (Removal of ventricular assist device, 
implantable intracorporeal, single ventricle), the AMA RUC reviewed the 
survey results and recommended the survey median work RVU of 40.00. 
Additionally the AMA RUC recommended a global period change from 090 to 
XXX. We agree with the AMA RUC-recommended global period change from 90 
to XXX. However, we disagree with the AMA RUC-recommended work RVU for 
CPT code 33980 and are proposing for CY 2012 an alternative work RVU of 
33.50, which is the survey 25th percentile work RVU. We believe the 
work RVU of 33.50 is more appropriate, given the significant reduction 
in physician times and decrease in the number and level of post-
operative visits that the AMA RUC included in the value of CPT code 
33980.
    For CPT code 36247 (Selective catheter placement, arterial system; 
initial third order or more selective abdominal, pelvic, or lower 
extremity artery branch, within a vascular family), the AMA RUC 
considered the survey results and recommended the survey median work 
RVU of 7.00 for this service. Additionally, the AMA RUC recommended a 
global period change from 090 to XXX. We agree with the AMA RUC-
recommended global period change from 90 to XXX. However, we disagree 
with the AMA RUC-recommended work RVU of 7.00 for CPT code 36247. We 
believe maintaining the current work RVU is more appropriate given the 
change to the global period. Accordingly we are proposing a work RVU of 
6.29 for CPT code 36247 for CY 2012.
    For CPT code 36825 (Creation of arteriovenous fistula by other than 
direct arteriovenous anastomosis (separate procedure); autogenous 
graft), the AMA RUC considered the survey data and ultimately 
recommended that

[[Page 32446]]

the current work RVU of this service, 15.13, be maintained.
    We disagree with the AMA RUC-recommended work RVU of 15.13 for CPT 
code 36825. As indicated by the most recent Medicare PFS claims data, 
CPT code 28122 is a code with a Site-of-Service anomaly. Therefore, in 
accordance with the policy discussed in section II.A. of this proposed 
notice, we removed the subsequent observation care service, reduced the 
discharge day management service to one-half, and adjusted times. As a 
result, we are proposing an alternative work RVU of 14.17 with 
refinements to the time for CPT code 36825 for CY 2012. A complete list 
of CMS time refinements can be found in Table 6.
13. Vascular Surgery
[GRAPHIC] [TIFF OMITTED] TP06JN11.032

    In the Fourth Five-Year Review, we identified CPT code 36819 as 
potentially misvalued through the Site-of-Service Anomaly screen, and 
we identified CPT code 36600 as potentially misvalued through the 
Harvard-Valued--Utilization > 30,000 screen. The Society for Vascular 
Surgery submitted additional CPT codes to be included in the Fourth 
Five-Year Review, including CPT codes 35188, 35612, 35800, 35840, 
35860, 37140, 37145, 37160, 37180, and 38181.
    The AMA RUC noted that it believed there is compelling evidence to 
change the work values for CPT codes 35188, 35612, 35800, 35840, and 
35860, since vascular surgery is one of the predominant providers of 
these services and had not participated in the original Harvard 
studies. In addition, the AMA RUC believes errors occurred in 
extrapolation of visits during the Harvard study, and apparent rank 
order anomalies may emerge when comparing these services to other 
vascular procedures.
    For CPT code 35188 (Repair, acquired or traumatic arteriovenous 
fistula; head and neck), the AMA RUC reviewed the survey results from 
25 (out of a sample size of 400) physicians and recommended the survey 
median work RVU of 18.50 for CPT code 35188.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
35188 and are proposing for CY 2012 an alternative work RVU of 18.00, 
which is the survey 25th percentile work RVU. We believe the work RVU 
of 18.00 is more appropriate, given the decrease in the number and 
level of post-operative visits that the AMA RUC included in the value 
of CPT code 35188.
    For CPT code 35612 (Bypass graft, with other than vein; subclavian-
subclavian), the AMA RUC reviewed the survey results from 25 (out of a 
sample size of 400) physicians and recommended a work RVU of 22.00 for 
CPT code 35612.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
35612 and are proposing for CY 2012 an alternative work RVU of 20.35, 
which is the survey 25th percentile work RVU. We believe the work RVU 
of 20.35 is more appropriate, given the decrease in the number and 
level of post-operative visits that the AMA RUC included in the value 
of CPT code 35612.
    For CPT code 35800 (Exploration for postoperative hemorrhage, 
thrombosis or infection; neck), the AMA RUC reviewed the survey results 
from 34 (out of a sample size of 400) physicians. Using magnitude 
estimation, the AMA RUC recommended that an appropriate work RVU for 
CPT code 35800 would be between the survey 25th percentile (12.00 RVU) 
and median (15.00 RVU) work value. Accordingly, the AMA RUC recommended 
a work RVU of 13.89 for CPT code 35800.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
35800 and are proposing for CY 2012 an alternative work RVU of 12.00, 
which is the survey 25th percentile work RVU. We believe the work RVU 
of 12.00 is more appropriate, given that two of the key reference codes 
to which this service has been compared have identical intra-service 
time (60 minutes), but significantly lower work RVUs.
    For CPT code 35840 (Exploration for postoperative hemorrhage, 
thrombosis or infection; abdomen), the AMA RUC reviewed the survey 
results from 34 (out of a sample size of 400) physicians. Using 
magnitude estimation, the AMA RUC recommended that an appropriate work 
RVU for CPT code 35840 would be between the survey 25th percentile 
(19.25 RVU) and median (22.30 RVU) work value. Accordingly, the AMA RUC 
recommended a work RVU of 21.19 for CPT code 35840.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
35840 and are proposing for CY 2012 an alternative work RVU of 20.75, 
which is between the survey 25th percentile and median work RVU. We 
believe the work RVU of 20.75 is more appropriate given the two 
reference codes to which this service has been compared.
    For CPT code 35860 (Exploration for postoperative hemorrhage, 
thrombosis or infection; extremity), the AMA RUC

[[Page 32447]]

reviewed the survey results from 34 (out of a sample size of 400) 
physicians. Using magnitude estimation, the AMA RUC recommended that an 
appropriate work RVU for CPT code 35860 would be between the survey 
25th percentile (15.25 RVUs) and median work value (18.00 RVUs). 
Accordingly, the AMA RUC recommended a work RVU of 16.89 for CPT code 
35860.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
35860 and are proposing for CY 2012 an alternative work RVU of 15.25, 
which is the survey 25th percentile work RVU. We believe this work RVU 
maintains appropriate relativity within the family of related services 
for the exploration of postoperative hemorrhage.
    For CPT code 36600 (Arterial puncture, withdrawal of blood for 
diagnosis), the AMA RUC reviewed the survey results from 38 (out of a 
sample size of 100) physicians and, based on comparisons to reference 
codes, recommended a work RVU of 0.32 for CPT code 36600.
    We agree with the AMA RUC's recommended work RVU and are proposing 
a work RVU of 0.32 for CPT code 36600 for CY 2012. In addition to the 
work RVU adjustment for CPT code 36600, we are refining the time 
associated with this code. Recent Medicare PFS claims data show that 
this service typically is performed on the same day as an E/M visit. We 
believe some of the activities conducted during the pre- and post-
service times of the procedure code and the E/M visit overlap and, 
therefore, should not be counted twice in developing the procedure's 
work value. As described in section II.A. of this proposed notice, to 
account for this overlap, we reduced the pre-service evaluation and 
post-service time by one-third. We believe that 3 minutes pre-service 
evaluation time and 3 minutes post-service time accurately reflect the 
time required to conduct the work associated with this service. A 
complete list of CMS time refinements can be found in Table 6.
    For CPT code 36819 (Arteriovenous anastomosis, open; by upper arm 
basilic vein transposition), which was identified as a code with a 
Site-of-Service anomaly, the AMA RUC reviewed the survey results from 
31 (out of a sample size of 400) physicians. The AMA RUC indicated that 
it believes this service should be categorized as one being typically 
performed in an inpatient hospital setting and recommended maintaining 
the current work RVU of 14.47.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
36819. The AMA RUC indicated in its summary of recommendations that the 
survey data show 97 percent (30 out of 31) of survey respondents stated 
they perform the procedure ``in the hospital.'' Of those respondents 
who stated that they typically perform the procedure in the hospital, 
33 percent (10 out of 30) stated that the patient is ``discharged the 
same day,'' 53 percent (16 out of 30) stated the patient is ``kept 
overnight (less than 24 hours),'' and 13 percent (4 out of 30) stated 
the patient is ``admitted (more than 24 hours).'' These responses make 
no distinction between the patient's status as an inpatient or 
outpatient of the hospital for stays of longer than 24 hours. As we 
discussed in section II.A. of this proposed notice, for codes with 
Site-of-Service anomalies, our policy is to remove any post-procedure 
inpatient visits remaining in the values for these codes and adjust 
physician times accordingly. It is also our policy for codes with Site-
of-Service anomalies to consistently include the value of half of a 
discharge day management service and adjust physician times 
accordingly. We are thus proposing an alternative work RVU for CY 2012 
of 13.29 with refinements in time for CPT code 36819. A complete list 
of CMS time refinements can be found in Table 6.
14. Excise Parotid Gland/Lesion
[GRAPHIC] [TIFF OMITTED] TP06JN11.033

    In the Fourth Five-Year Review, we identified CPT codes 42415 and 
42420 as Site-of-Service anomaly codes.
    For CPT code 42415 (Excision of parotid tumor or parotid gland; 
lateral lobe, with dissection and preservation of facial nerve), the 
AMA RUC reviewed the survey data and, based on magnitude estimation, 
the AMA RUC recommended that the current work RVU of this service, 
18.12, be maintained.
    We disagree with the AMA RUC-recommended work RVU of 18.12 for CPT 
code 42415. As indicated by the most recent Medicare PFS claims data, 
CPT code 42415 is a code with a Site-of-Service anomaly. Therefore, in 
accordance with the policy discussed in section II.A. of this proposed 
notice, we removed the subsequent observation care service, reduced the 
discharge day management service to one-half, and adjusted times. As a 
result, we are proposing an alternative work RVU of 17.16 with 
refinements to the time for CPT code 42415 for CY 2012. A complete list 
of CMS time refinements can be found in Table 6.
    For CPT code 42420 (Excision of parotid tumor or parotid gland; 
total, with dissection and preservation of facial nerve), the AMA RUC 
reviewed survey results and, based on magnitude estimation, the AMA RUC 
recommended that the current work RVU of this service, 21.00, be 
maintained.
    We disagree with the AMA RUC-recommended work RVU of 21.00 for CPT 
code 42420. As indicated by the most recent Medicare PFS claims data, 
CPT code 42420 is a code with a Site-of-Service anomaly. Therefore, in 
accordance with the policy discussed in section II.A. of this proposed 
notice, we removed the subsequent observation care service, reduced the 
discharge day management service to one-half, and adjusted times. As a 
result, we are proposing an alternative work RVU of 19.53 with 
refinements to the time for CPT code 42420 for CY 2012. A complete list 
of CMS time refinements can be found in Table 6.
15. Endoscopic Cholangiopancreatography

[[Page 32448]]

[GRAPHIC] [TIFF OMITTED] TP06JN11.034

    In the Fourth Five-Year Review, we identified CPT code 43262 as 
potentially misvalued through the Harvard Valued--Utilization > 30,000 
screen.
    For CPT code 43262 (Endoscopic retrograde cholangiopancreatography 
(ERCP); with sphincterotomy/papillotomy), the AMA RUC reviewed the 
service and believes that the specialty did not provide compelling 
evidence to change the current value of the service. Therefore, the AMA 
RUC recommended maintaining the current work RVU of 7.38 for CPT code 
43262.
    We are proposing to maintain the current work RVU of 7.38 and the 
current physician time for CPT code 43262 for CY 2012. However, we are 
requesting that the AMA RUC undertake a comprehensive review of the 
entire family of ERCP codes, including the base CPT code 43260, and 
provide CMS with work RVU recommendations. We note that based on a 
preliminary review of the intra-service times for these codes, we are 
concerned the codes in this family are potentially misvalued.
16. Sigmoidoscopy
[GRAPHIC] [TIFF OMITTED] TP06JN11.035

    In the Fourth Five-Year Review, CMS identified CPT code 45331 as 
potentially misvalued through the Harvard-Valued--Utilization > 30,000 
screen.
    For CPT code 45331 (Sigmoidoscopy, flexible; with biopsy, single or 
multiple), the AMA RUC reviewed the survey results and determined that 
the survey data support the current value of this service. Taking into 
consideration the 75th percentile of the survey results, the AMA RUC 
recommended a pre-service time of 15 minutes, intra-service time of 15 
minutes, and post-service time of 10 minutes. Accordingly, the AMA RUC 
recommended a work RVU of 1.15 for CPT code 45331.
    We agree with the AMA RUC's recommended work RVU and are proposing 
a work RVU of 1.15 for CPT code 45331 for CY 2012. However, while the 
AMA RUC recommended pre-service times based on the 75th percentile of 
the survey results, we believe it is more appropriate to accept the 
median survey physician times. Accordingly, we are refining the times 
to the following: 5 minutes for pre-evaluation; 5 minutes for pre-
service other, 5 minutes for pre- dress, scrub, and wait; 10 minutes 
intra-service; and 10 minutes immediate post-service. A complete list 
of CMS time refinements can be found in Table 6.
17. Laparoscopic Cholecystectomy
[GRAPHIC] [TIFF OMITTED] TP06JN11.036

    In the Fourth Five-Year Review, CMS identified CPT code 47563 as 
potentially misvalued through the Harvard Valued--Utilization > 30,000 
screen and Site-of-Service Anomaly screen. The AMA RUC reviewed CPT 
codes 47564 and 47563.
    For CPT code 47563 (Laparoscopy, surgical; cholecystectomy with 
cholangiography), the AMA RUC reviewed the survey results and 
recommended that this service be valued as a service performed 
predominately in the facility setting, as the survey data indicated 
that a majority of patients have an overnight stay. Because some 
respondents stated that the typical patient would be kept at overnight 
in the hospital, the AMA RUC recommended a full day discharge 
management service be included in the value of the service. The AMA RUC 
recommended maintaining the current work RVU of 12.11 for CPT code 
47563.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
47563. While the survey data show 95 percent (57 out of 60) of survey 
respondents stated they perform the procedure ``in the hospital,'' of 
those respondents who stated that they typically perform the procedure 
in the hospital, 30 percent (17 out of 57) stated that the patient is 
``discharged the same day,'' 46 percent (26 out of 57) stated the 
patient is ``kept overnight (less than 24 hours),'' and 25 percent (14 
out of 57) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As we discussed in section II.A. of this proposed notice, for 
codes with Site-of-Service anomalies, our policy is to remove any post-
procedure inpatient visits remaining in the values for these codes and 
adjust physician times accordingly. It is also our policy for codes 
with Site-of-Service anomalies to consistently include the value of 
half of a discharge day management service, adjusting physician times 
accordingly. We are thus proposing an alternative work RVU of 11.47 
with refinements in time for CPT code 47563 for CY 2012.

[[Page 32449]]

A complete list of CMS time refinements can be found in Table 6.
    For CPT code 47564 (Laparoscopy, surgical; cholecystectomy with 
exploration of common duct), the AMA RUC reviewed the survey results 
and determined that the 25th survey percentile was appropriate for this 
service. Accordingly, the AMA RUC recommended a work RVU of 20.00 for 
CPT code 47564.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
47564 and are proposing for CY 2012 an alternative work RVU of 18.00, 
which is the survey low work RVU. We are accepting the AMA RUC 
recommended median survey times and believe the work RVU of 18.00 for 
CPT code 35860 is more appropriate given the significant reduction in 
recommended physician times in comparison to the current times.
18. Hernia Repair
[GRAPHIC] [TIFF OMITTED] TP06JN11.037

    In 2007, the AMA RUC's Relativity Assessment Workgroup identified 
CPT codes 49507, 49521 and 49587 as potentially misvalued through the 
Site-of-Service Anomaly screen. The American College of Surgeons (ACS) 
surveyed these codes, and the AMA RUC issued recommended work values 
for these codes to CMS for CY 2010. In the CY 2011 PFS final rule with 
comment period (75 FR 73221), we reiterated that in the CY 2010 PFS 
final rule with comment period (74 FR 61776 through 61778) we indicated 
that although we would accept the AMA RUC valuations for these Site-of-
Service anomaly codes on an interim basis through CY 2010, we had 
ongoing concerns about the methodology used by the AMA RUC to review 
these services. We requested that the AMA RUC reexamine the Site-of-
Service anomaly codes and use the building block methodology to revalue 
the services (74 FR 62777 and 75 FR 73221). CPT codes 49507, 49521, and 
49587 were among those CY 2010 Site-of-Service anomaly codes, and were 
reviewed again by the AMA RUC as a part of the Fourth Five-Year Review.
    For CPT code 49507 (Repair initial inguinal hernia, age 5 years or 
over; incarcerated or strangulated), the AMA RUC used magnitude 
estimation and recommended a work RVU of 9.97 for CPT code 49507 for CY 
2010, which was slightly higher than the survey 25th percentile value. 
In CY 2010, while CMS adopted the AMA RUC-recommended work value on an 
interim final basis and referred the service back to the AMA RUC to be 
reexamined, the work RVU for CPT code 49507 used under the PFS was 
increased to 10.05 based on the redistribution of RVUs that resulted 
from the CMS policy to no longer recognize the CPT consultation codes. 
Upon re-review for CY 2012 as part of the Fourth Five-Year Review of 
Work, the AMA RUC determined that CPT code 49507 had been accurately 
valued in its recommendation for CY 2010 with support from reference 
services and specialty survey data, and stated that it found no 
compelling evidence to change the current physician work value of this 
service. The AMA RUC ultimately recommended that the current work RVU 
of 10.05 be maintained for CPT code 49507 for CY 2012.
    We disagree with the AMA RUC-recommended work RVU of 10.05 for CPT 
code 49507. The AMA RUC indicated in its summary of recommendations 
that the survey data show Ninety-eight percent of survey respondents 
stated they perform the procedure ``in the hospital.'' Of those 
respondents who stated that they typically perform the procedure in the 
hospital, 17 percent stated that the patient is ``discharged the same 
day,'' 40 percent stated the patient is ``kept overnight (less than 24 
hours),'' and 43 percent stated the patient is ``admitted (more than 24 
hours).'' These responses make no distinction between the patient's 
status as an inpatient or outpatient of the hospital for stays of 
longer than 24 hours. As indicated by the most recent PFS claims data, 
CPT code 49507 is a code with a Site-of-Service anomaly. Therefore, in 
accordance with the policy discussed in section II.A. of this proposed 
notice, we removed the subsequent observation care service, reduced the 
discharge day management service to one-half, and adjusted times. As a 
result, we are proposing an alternative work RVU of 9.09 with 
refinements to the time for CPT code 49507 for CY 2012. A complete list 
of CMS time refinements can be found in Table 6.
    For CPT code 49521 (Repair recurrent inguinal hernia, any age; 
incarcerated or strangulated), the AMA RUC used magnitude estimation 
and recommended a work RVU of 12.36 for CY 2010, which fell between the 
survey 25th percentile and median work value estimates. In CY 2010, 
while CMS adopted the AMA RUC-recommended work value on an interim 
final basis and referred the service back to the AMA RUC to be 
reexamined, the work RVU for CPT code 49521 used under the PFS was 
increased to 12.44 based on the redistribution of RVUs that resulted 
from the CMS policy to no longer recognize the CPT consultation codes. 
Upon re-review for CY 2012, the AMA RUC determined that CPT code 49521 
was accurately valued in its recommendation for CY 2010, with support 
from reference services and specialty survey data, and stated that it 
found no compelling evidence to change the current physician work value 
of this service. The AMA RUC ultimately recommended that the current 
work RVU of 12.44 be maintained for CPT code 49521 in CY 2012.
    We disagree with the AMA RUC-recommended work RVU of 12.44 for CPT 
code 49521. The AMA RUC indicated in its summary of recommendations 
that the survey data show 99 percent of survey respondents stated they 
perform the procedure ``in the hospital.'' Of those respondents who 
stated that they typically perform the procedure in the hospital, 18 
percent stated that the patient is ``discharged the same day,'' 37 
percent stated the patient is ``kept overnight (less than 24 hours),'' 
and 45 percent stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between

[[Page 32450]]

the patient's status as an inpatient or outpatient of the hospital for 
stays of longer than 24 hours. As indicated by the most recent PFS 
claims data, CPT code 49521 is a code with a Site-of-Service anomaly. 
Therefore, in accordance with the policy discussed in section II.A. of 
this proposed notice, we removed the subsequent observation care 
service, reduced the discharge day management service to one-half, and 
adjusted times. As a result, we are proposing an alternative work RVU 
of 11.48 with refinements to the time for CPT code 49521 for CY 2012. A 
complete list of CMS time refinements can be found in Table 6.
    For CPT code 49587 (Repair umbilical hernia, age 5 years or over; 
incarcerated or strangulated), the AMA RUC used magnitude estimation 
and recommended a work RVU of 7.96 for CY 2010, which was slightly 
below the survey 25th percentile physician work value estimate. Under 
the CY 2010 PFS, the work RVU for CPT code 49587 was increased to 8.04 
based on the redistribution of RVUs resulting from the CMS policy to no 
longer recognize the CPT consultation codes. Upon re-review for CY 
2012, the AMA RUC determined that CPT code 49587 was accurately valued 
in its CY 2010 recommendation, with support from reference services and 
specialty survey data, and stated that it found no compelling evidence 
to change the current physician work value of this service. The AMA RUC 
ultimately recommended that the current work RVU of 8.04 be maintained 
for CPT code 49587 for CY 2012.
    We disagree with the AMA RUC-recommended work RVU of 8.04 for CPT 
code 49587. The AMA RUC indicated in its summary of recommendations 
that the survey data show 100 percent of survey respondents stated they 
perform the procedure ``in the hospital.'' Of those respondents who 
stated that they typically perform the procedure in the hospital, 30 
percent stated that the patient is ``discharged the same day,'' 42 
percent stated the patient is ``kept overnight (less than 24 hours),'' 
and 29 percent stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As indicated by the most recent PFS claims data, CPT code 49587 
is a code with a Site-of-Service anomaly. Therefore, in accordance with 
the policy discussed in section II.A. of this proposed notice, we 
removed the subsequent observation care service, reduced the discharge 
day management service to one-half, and adjusted times. As a result, we 
are proposing an alternative work RVU of 7.08 with refinements to the 
time for CPT code 49587 for CY 2012. A complete list of CMS time 
refinements can be found in Table 6.
19. Laparoscopic Hernia Repair
[GRAPHIC] [TIFF OMITTED] TP06JN11.038

    For CY 2009, the CPT Editorial Panel created six new CPT codes to 
describe the specific levels of work associated with abdominal hernia 
repairs that are performed frequently with laparoscopic techniques. We 
accepted the AMA RUC's original work RVU recommendation for these 
services for CY 2009. However, we identified 4 of these laparoscopic 
hernia repair CPT codes, specifically CPT codes 49652, 49653, 49654 and 
49655, as potentially misvalued through the Site-of-Service Anomaly 
screen, and requested that they be reviewed by the AMA RUC for Fourth 
Five-Year Review.
    For CPT code 49652 (Laparoscopy, surgical, repair, ventral, 
umbilical, spigelian or epigastric hernia (includes mesh insertion, 
when performed); reducible), for CY 2009, the AMA RUC used magnitude 
estimation and recommended the survey 25th percentile work RVU of 12.80 
for CPT code 49652 for CY 2009. CMS accepted this recommendation. For 
CY 2010, the work RVU for CPT code 49652 was increased to 12.88 based 
on the redistribution of RVUs resulting from the CMS policy to no 
longer recognize the CPT consultation codes. Upon re-review for CY 
2012, the AMA RUC determined that CPT code 49652 was accurately valued 
in its recommendation for CY 2009, with support from reference services 
and specialty survey data, and stated that it found no compelling 
evidence to change the current physician work value of this service. 
The AMA RUC ultimately recommended that the current work RVU of 12.88 
be maintained for CPT code 49652 for CY 2012.
    We disagree with the AMA RUC-recommended work RVU of 12.88 for CPT 
code 49652. The AMA RUC indicated in its summary of recommendations 
that the survey data show 100 percent of survey respondents stated they 
perform the procedure ``in the hospital.'' Of those respondents who 
stated that they typically perform the procedure in the hospital, 16 
percent stated that the patient is ``discharged the same day,'' 60 
percent stated the patient is ``kept overnight (less than 24 hours),'' 
and 24 percent stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As indicated by the most recent PFS claims data, CPT code 49652 
is a code with a Site-of-Service anomaly. In its recommendation to us, 
the AMA RUC asserted that Medicare claims data for this service are 
still new and may not reflect accurate Medicare utilization for this 
procedure. The most recent PFS claims data show that outpatient 
utilization for this code is well above the Site-of-Service anomaly 
threshold of greater than 50 percent, and we will continue to monitor 
the data to ensure that this CPT code, and all CPT codes, are valued 
appropriately for their site-of-service. In accordance with the policy 
discussed in section II.A. of this proposed notice, we removed the 
subsequent observation care service, reduced the discharge day 
management service to one-half, and adjusted times. As a result, we are 
proposing an alternative work RVU of 11.92 with refinements to the time 
for CPT code 49652 for CY 2012. A

[[Page 32451]]

complete list of CMS time refinements can be found in Table 6.
    For CPT code 49653 (Laparoscopy, surgical, repair, ventral, 
umbilical, spigelian or epigastric hernia (includes mesh insertion, 
when performed); incarcerated or strangulated), for CY 2009, the AMA 
RUC used magnitude estimation and recommended the survey 25th 
percentile work RVU of 16.10 for CPT code 49653 for CY 2009. CMS 
accepted this recommendation. For CY 2010, the work RVU for CPT code 
49653 was increased to 16.21 based on the redistribution of RVUs 
resulting from the CMS policy to no longer recognize the CPT 
consultation codes. Upon re-review for CY 2012, the AMA RUC determined 
that CPT code 49653 was accurately valued in its CY 2009 
recommendation, with support from reference services and specialty 
survey data, and stated that it found no compelling evidence to change 
the current physician work value of this service. The AMA RUC 
ultimately recommended that the current work RVU of 16.21 be maintained 
for CPT code 49653 for CY 2012.
    We disagree with the AMA RUC-recommended work RVU of 16.21 for CPT 
code 49653. The AMA RUC indicated in its summary of recommendations 
that the survey data show 100 percent of survey respondents stated they 
perform the procedure ``in the hospital.'' Of those respondents who 
stated that they typically perform the procedure in the hospital, 9 
percent stated that the patient is ``discharged the same day,'' 16 
percent stated the patient is ``kept overnight (less than 24 hours),'' 
and 76 percent stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As indicated by the most recent PFS claims data, CPT code 49653 
is a code with a Site-of-Service anomaly. In its recommendation to us, 
the AMA RUC asserted that Medicare claims data for this service are 
still new and may not reflect accurate Medicare utilization for this 
procedure. The most recent PFS claims data show that outpatient 
utilization for this code is well above the Site-of-Service anomaly 
threshold of greater than 50 percent, and we will continue to monitor 
the data to ensure that this CPT code, and all CPT codes, are valued 
appropriately for their site-of-service. In accordance with the policy 
discussed in section II.A. of this proposed notice, we removed the 
subsequent observation care service, reduced the discharge day 
management service to one-half, and adjusted times. As a result, we are 
proposing an alternative work RVU of 14.94 with refinements to the time 
for CPT code 49653 for CY 2012. A complete list of CMS time refinements 
can be found in Table 6.
    For CPT code 49654 (Laparoscopy, surgical, repair, incisional 
hernia (includes mesh insertion, when performed); reducible), for CY 
2009 the AMA RUC used magnitude estimation and recommended the survey 
25th percentile work RVU of 14.95 for CPT code 49654 for CY 2009. We 
accepted this recommendation. For CY 2010, the work RVU for CPT code 
49654 was increased to 15.03 based on the redistribution of RVUs 
resulting from the CMS policy to no longer recognize the CPT 
consultation codes. Upon re-review for CY 2012, the AMA RUC determined 
that CPT code 49654 was accurately valued in its CY 2009 
recommendation, with support from reference services and specialty 
survey data, and stated that it found no compelling evidence to change 
the current physician work value of this service. The AMA RUC 
ultimately recommended that the current work RVU of 15.03 be maintained 
for CPT code 49654 for CY 2012.
    We disagree with the AMA RUC-recommended work RVU of 15.03 for CPT 
code 49654. The AMA RUC indicated in its summary of recommendations 
that the survey data show 100 percent of survey respondents stated they 
perform the procedure ``in the hospital.'' Of those respondents who 
stated that they typically perform the procedure in the hospital, 10 
percent stated that the patient is ``discharged the same day,'' 33 
percent stated the patient is ``kept overnight (less than 24 hours),'' 
and 56 percent stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As indicated by the most recent PFS claims data, CPT code 49654 
is a code with a Site-of-Service anomaly. In its recommendation to us, 
the AMA RUC asserted that Medicare claims data for this service are 
still new and may not reflect accurate Medicare utilization for this 
procedure. The most recent PFS claims data show that outpatient 
utilization for this code is well above the Site-of-Service anomaly 
threshold of greater than 50 percent, and we will continue to monitor 
the data to ensure that this CPT code, and all CPT codes, are valued 
appropriately for their site-of-service. In accordance with the policy 
discussed in section II.A. of this proposed notice, we removed the 
subsequent observation care service, reduced the discharge day 
management service to one-half, and adjusted times. As a result, we are 
proposing an alternative work RVU of 13.76 with refinements to the time 
for CPT code 49654 for CY 2012. A complete list of CMS time refinements 
can be found in Table 6.
    For CPT code 49655 (Laparoscopy, surgical, repair, incisional 
hernia (includes mesh insertion, when performed); incarcerated or 
strangulated), for CY 2009 the AMA RUC crosswalked CPT code 49655 to 
CPT code 43280 (Laparoscopy, surgical, esophagogastric fundoplasty 
(e.g., Nissen, Toupet procedures)) (work RVU = 18.10), and recommended 
a work RVU of 18.00. We accepted this recommendation. For CY 2010, the 
work RVU for CPT code 49655 was increased to 18.11 based on the 
redistribution of RVUs resulting from the CMS policy to no longer 
recognize the CPT consultation codes. Upon re-review for CY 2012, the 
AMA RUC decided that CPT code 49655 was accurately valued in its CY 
2009 recommendation, with support from reference services and specialty 
survey data, and stated that it found no compelling evidence to change 
the current physician work value of this service. The AMA RUC 
ultimately recommended that the current work RVU of 18.11 be maintained 
for CPT code 49655 for CY 2012.
    We disagree with the AMA RUC-recommended work RVU of 18.11 for CPT 
code 49655. The AMA RUC indicated in its summary of recommendations 
that the survey data show 100 percent of survey respondents stated they 
perform the procedure ``in the hospital.'' Of those respondents who 
stated that they typically perform the procedure in the hospital, 5 
percent stated that the patient is ``discharged the same day,'' 8 
percent stated the patient is ``kept overnight (less than 24 hours),'' 
and 87 percent stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As indicated by the most recent PFS claims data, CPT code 49655 
is a code with a Site-of-Service anomaly. In its recommendation to us, 
the AMA RUC asserted that Medicare claims data for this service are 
still new and may not reflect accurate Medicare utilization for this 
procedure. The most recent PFS claims data show that outpatient 
utilization for this code is above the Site-of-Service anomaly 
threshold of greater than 50 percent, and we will continue to monitor 
the data to ensure that this CPT code, and all CPT codes, are valued 
appropriately for their site-of-service. In accordance with the

[[Page 32452]]

policy discussed in section II.A. of this proposed notice, we removed 
the subsequent observation care service, reduced the discharge day 
management service to one-half, and adjusted times. As a result, we are 
proposing an alternative work RVU of 16.84 with refinements to the time 
for CPT code 49655 for CY 2012. A complete list of CMS time refinements 
can be found in Table 6.
20. Urologic Procedures
[GRAPHIC] [TIFF OMITTED] TP06JN11.039

    In the Fourth Five-Year Review, we identified CPT codes 51705, 
52005 and 52310 as potentially misvalued through the Harvard-Valued--
Utilization > 30,000 screen. CPT codes 51710, 52007 and 52315 were 
added as part of the family of services for AMA RUC review. In 
addition, we identified CPT codes 52630, 52649, 53440 and 57288 as 
potentially misvalued through the Site-of-Service Anomaly screen. The 
specialty agreed to add CPT codes 52640 and 57287 as part of the family 
of services for AMA RUC review.
    For CPT code 51710 (Change of cystostomy tube; complicated), the 
AMA RUC noted that a request was sent to CMS to have the global service 
period changed from a 10-day global period (which includes RVUs for the 
same day pre-operative period and for a 10-day post-operative period) 
to a 0-day global period (which only includes RVUs for the same day 
pre- and post-operative period). The AMA RUC indicated that in the 
standards of care for this procedure, there is no hospital time and 
there are no follow up visits. The AMA RUC also noted that while the 
service was surveyed as a 10-day global, the respondents inadvertently 
included a hospital visit, CPT code 99231(Subsequent hospital care), 
and overvalued the physician work. Consequently, the AMA RUC did not 
use the survey results to value the code. Rather, comparing the 
physician work within the family of services, the AMA RUC compared CPT 
code 51710 to CPT code 51705 (Change of cystostomy tube; simple) and 
recommended a work RVU of 1.35 for CPT code 51710.
    We agree with the AMA RUC's recommended work RVU and are proposing 
a work RVU of 1.35 for CPT code 51710 for CY 2012. We also agree to 
change the global period from 10 to zero days. However, we note that 
while we believe that changing a cystostomy tube in a complicated 
patient may be more time consuming than in a patient that requires a 
simple cystostomy tube change, we believe that the pre-positioning time 
is unnecessarily high given the recommended pre-positioning time of 5 
minutes for CPT code 51705, which has an identical pre-positioning work 
description. Hence, we are making refinements in time for CPT code 
51710 for CY 2012. A complete list of CMS time refinements can be found 
in Table 6.
    For CPT code 52630 (Transurethral resection; residual or regrowth 
of obstructive prostate tissue including control of postoperative 
bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral 
calibration and/or dilation, and internal urethrotomy are included)), 
the AMA RUC reviewed the survey results and recommended that this 
service be valued as a service performed predominately in the facility 
setting, as the survey data indicated that a majority of patients have 
an overnight stay. Because the majority of respondents stated that the 
typical patient would be kept overnight in the hospital, the AMA RUC 
recommended that one inpatient hospital visit and a full day discharge 
management service be included in the value of the service for CPT code 
52630. The AMA RUC stated that it ultimately did not believe there was 
compelling evidence to signal a recent change in physician work. 
Accordingly, the AMA RUC recommended maintaining the current work RVU 
of 7.73 for CPT code 52630.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
52630. While the survey data show 93 percent (37 out of 40) of survey 
respondents stated they perform the procedure ``in the hospital,'' of 
those respondents who stated that they typically perform the procedure 
in the hospital, 3 percent (1 out of 40) stated that the patient is 
``discharged the same day,'' 43 percent (17 out of 40) stated the 
patient is ``kept overnight (less than 24 hours),'' and 54 percent (22 
out of 40) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. As we discussed in section II.A. of this proposed notice, we 
believe that the 23-hour stay issue encompasses several scenarios. The 
typical patient is commonly in the hospital for less than 24 hours, 
which often means the patient may indeed stay overnight in the 
hospital. On occasion, the patient may stay longer than a single night 
in the

[[Page 32453]]

hospital; however, in both cases, the patient is considered for 
Medicare purposes to be a hospital outpatient, not an inpatient. Given 
that the most recent Medicare PFS claims data indicate this service is 
typically (more than 50 percent of the time) furnished in the 
outpatient setting, we believe it is appropriate to remove the post-
procedure inpatient visit remaining in the AMA RUC-recommended value 
and adjust the physician times accordingly. We also reduced the 
discharge day management service to one-half. We are thus proposing an 
alternative work RVU of 6.55 with refinements in time for CPT code 
47563 for CY 2012. A complete list of CMS time refinements can be found 
in Table 6.
    For CPT code 52649 (Laser enucleation of the prostate with 
morcellation, including control of postoperative bleeding, complete 
(vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or 
dilation, internal urethrotomy and transurethral resection of prostate 
are included if performed)), a Site-of-Service anomaly code, the AMA 
RUC reviewed the survey results of 16 (out of a sample size of 869) 
physicians. The AMA RUC recommended that this service be valued as a 
service performed predominately in the facility setting. Using 
magnitude estimation, the AMA RUC agreed that the 25th percentile 
survey value, which is lower than the current work RVU, was 
appropriate. The AMA RUC ultimately recommended a work RVU of 15.20 for 
CPT code 52649.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
52649. While the survey data show 94 percent (15 out of 16) of survey 
respondents stated they perform the procedure ``in the hospital,'' of 
those respondents who stated that they typically perform the procedure 
in the hospital, 33 percent (5 out of 16) stated that the patient is 
``discharged the same day,'' 54 percent (9 out of 16) stated the 
patient is ``kept overnight (less than 24 hours),'' and 13 percent (2 
out of 16) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. Nevertheless, the survey data confirm the most recent Medicare 
PFS claims data which show that CPT code 52649 is a code with a Site-
of-Service anomaly. Accordingly, we applied our policy for a 23-hour 
stay service and reduced the discharge day management service to one-
half. We are proposing an alternative work RVU of 14.56 with 
refinements in time for CPT code 52649 for CY 2012. A complete list of 
CMS time refinements can be found in Table 6.
    For CPT code 53440 (Sling operation for correction of male urinary 
incontinence (eg, fascia or synthetic)), the AMA RUC reviewed the 
survey results from 30 (out of a sample size of 717) physicians. The 
AMA RUC recommended that this service be valued as a service performed 
predominately in the facility setting. Using magnitude estimation, the 
AMA RUC agreed that the median survey value, which is lower than the 
current work RVU, was appropriate. The AMA RUC ultimately recommended a 
work RVU of 14.00 for CPT code 53440.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
53440. While the survey data show 97 percent (29 out of 30) of survey 
respondents stated they perform the procedure ``in the hospital,'' of 
those respondents who stated that they typically perform the procedure 
in the hospital, 38 percent (11 out of 30) stated that the patient is 
``discharged the same day,'' 59 percent (18 out of 30) stated the 
patient is ``kept overnight (less than 24 hours),'' and 3 percent (1 
out of 30) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. Nevertheless, the survey data show that the vast majority of 
responders indicated CPT code 53440 is typically performed in the 
hospital setting as an outpatient rather than an inpatient service. The 
survey data confirm the most recent Medicare PFS claims data which show 
that CPT code 53440 is a code with a Site-of-Service anomaly. 
Accordingly, we applied our policy for a 23-hour stay service and 
reduced the discharge day management service to one-half. We are 
proposing an alternative work RVU of 13.36 with refinements in time for 
CPT code 53440 for CY 2012. A complete list of CMS time refinements can 
be found in Table 6.
21. Removal of Thyroid/Parathyroid
[GRAPHIC] [TIFF OMITTED] TP06JN11.040

    In the Fourth Five-Year Review, we identified CPT codes 60220, 
60240 and 60500 as potentially misvalued through the Site-of-Service 
Anomaly screen.
    For CPT code 60220 (Total thyroid lobectomy, unilateral; with or 
without isthmusectomy), the AMA RUC reviewed the survey results from 35 
(out of a sample size of 118) physicians. The AMA RUC recommended that 
this service be valued as a service performed predominately in the 
facility setting. The AMA RUC indicated that since the typical patient 
is kept overnight, the AMA RUC believes that one inpatient hospital 
visit as well as one discharge day management service should be 
maintained in the post-operative visits for this service. Using 
magnitude estimation, the AMA RUC recommended the current work RVU of 
12.37 for CPT code 60220.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
60220. While the survey data show 97 percent (34 out of 35) of survey 
respondents stated they perform the procedure ``in the hospital,'' of 
those respondents who stated that they typically perform the procedure 
in the hospital, 18 percent (6 out of 34) stated that the patient is 
``discharged the same day,'' 79 percent (27 out of 34) stated the 
patient is ``kept overnight (less than 24 hours),'' and 3 percent (1 
out of 34) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. Nevertheless, the survey data show that the majority of 
responders

[[Page 32454]]

indicated CPT code 60220 is typically performed in the hospital setting 
as an outpatient rather than an inpatient service. The survey data 
confirm the most recent Medicare PFS claims which show that CPT code 
60220 is a code with a Site-of-Service anomaly. Accordingly, in 
applying the policy for a 23-hour stay service, we removed the hospital 
visit, reduced the discharge day management service to one-half, and 
adjusted times. We are proposing an alternative work RVU of 11.19 with 
refinements in time for CPT code 60220 for CY 2012. A complete list of 
CMS time refinements can be found in Table 6.
    For CPT code 60240 (Thyroidectomy, total or complete), the AMA RUC 
reviewed the survey results from 35 (out of a sample size of 118) 
physicians. Using magnitude estimation, the AMA RUC believed that 
maintaining the current work RVU is appropriate. The AMA RUC ultimately 
recommended the current work RVU of 16.22 for CPT code 60240.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
60220. Of the 97 percent of respondents that stated they perform the 
procedure ``in the hospital,'' 100 percent stated that the patient is 
either ``discharged the same day'' or ``kept overnight (less than 24 
hours).'' The survey data confirm the most recent Medicare PFS claims 
data which show that CPT code 60240 is a code with a Site-of-Service 
anomaly. Accordingly, we believe it is appropriate to remove the post-
procedure inpatient visit remaining in the value and adjust the 
physician times accordingly. We also reduced the discharge day 
management service to one-half, consistent with our 23 hour stay 
service policy. We are proposing an alternative work RVU of 15.04 with 
refinements in time for CPT code 60240 for CY 2012. A complete list of 
CMS time refinements can be found in Table 6.
    For CPT code 60500 (Parathyroidectomy or exploration of 
parathyroid(s);), the AMA RUC reviewed the survey results from 35 (out 
of a sample size of 118) physicians. The AMA RUC recommended that this 
service be valued as a service performed predominately in the facility 
setting. The AMA RUC indicated that since the typical patient is kept 
overnight, the AMA RUC believes that one hospital visit as well as one 
discharge day management service should be maintained in the post-
operative visits for this service. Using magnitude estimation, the AMA 
RUC ultimately recommended the current work RVU of 16.78 for CPT code 
60500.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
60500. While the survey data show 97 percent (34 out of 35) of survey 
respondents stated they perform the procedure ``in the hospital,'' of 
those respondents who stated that they typically perform the procedure 
in the hospital, 18 percent (6 out of 34) stated that the patient is 
``discharged the same day,'' 44 percent (15 out of 34) stated the 
patient is ``kept overnight (less than 24 hours),'' and 38 percent (13 
out of 34) stated the patient is ``admitted (more than 24 hours).'' 
These responses make no distinction between the patient's status as an 
inpatient or outpatient of the hospital for stays of longer than 24 
hours. Nevertheless, the survey data show that the majority of 
responders indicated CPT code 60500 is typically performed in the 
hospital setting as an outpatient rather than an inpatient service. The 
survey data confirm the most recent Medicare PFS claims data which show 
that CPT code 60500 is a code with a Site-of-Service anomaly. 
Accordingly, we removed the hospital visit, reduced the discharge day 
management service to one-half, and adjusted times. We are proposing an 
alternative work RVU of 15.60 with refinements in time for CPT code 
60500 for CY 2012. A complete list of CMS time refinements can be found 
in Table 6.
22. Implant Neuroelectrodes
[GRAPHIC] [TIFF OMITTED] TP06JN11.041

    In the Fourth Five-Year Review, CMS identified CPT code 63655 
(Laminectomy for implantation of neurostimulator electrodes, plate/
paddle, epidural) as potentially misvalued through the Site-of-Service 
Anomaly screen. CY 2009 Medicare PFS claims data indicated that for the 
typical case (greater than 50 percent), this service was not performed 
in the inpatient hospital setting and, therefore, we requested in the 
CYs 2010 and 2011 PFS final rules that the AMA RUC review this service 
again.
    For CPT code 63655 (Laminectomy for implantation of neurostimulator 
electrodes, plate/paddle, epidural), the associated specialty societies 
indicated that this service was recently surveyed and reviewed by the 
AMA RUC in April 2009 and concluded that there was no reason to believe 
another survey would result in different data requiring a change in the 
AMA RUC's previous discussion and recommendation. Accordingly, the AMA 
RUC recommended maintaining the current work RVU of 11.56, as well as 
the current physician time components.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
63655. We note that according to the survey data provided by the AMA 
RUC, of the 90 percent of respondents that stated they perform the 
procedure ``in the hospital,'' 18 percent stated that the patient is 
``discharged the same day'' and 55 percent stated that the patient was 
``kept overnight (less than 24 hours).'' Given that the most recently 
available Medicare PFS claims data continue to show the typical case is 
not an inpatient, and that the survey data for this code suggest the 
typical case is a 23 hour stay service, we believe it is appropriate to 
apply our established policy and reduce the discharge day management 
service to one-half. We are thus proposing an alternative work RVU of 
10.92 with refinements in time for CPT code 63655 for CY 2012. A 
complete list of CMS time refinements can be found in Table 6.
23. Injection of Anesthetic Agent

[[Page 32455]]

[GRAPHIC] [TIFF OMITTED] TP06JN11.042

    In the Fourth Five-Year Review, CMS identified CPT code 64405 as 
potentially misvalued through the Harvard-Valued--Utilization > 30,000 
screen.
    For CPT code 64405 (Injection, anesthetic agent; greater occipital 
nerve), the AMA RUC reviewed the survey results and recommended the 
median survey work RVU of 1.00 for CPT code 64405.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
64405. We believe this code is comparable to the key reference CPT code 
20526 (Injection, therapeutic (eg, local anesthetic, corticosteroid), 
carpal tunnel) (work RVU = 0.94). Accordingly, we are proposing an 
alternative work RVU of 0.94 for CPT code 64405 for CY 2012.
24. Gastric Emptying Study
[GRAPHIC] [TIFF OMITTED] TP06JN11.043

    In the Fourth Five-Year Review, we identified CPT code 78264 as 
potentially misvalued through the Harvard-Valued--Utilization > 30,000 
screen.
    For CPT code 78264 (Gastric emptying study), the AMA RUC reviewed 
the survey results and recommended the survey median work RVU of 0.95 
for CPT code 78264.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
78264. We believe the 25th percentile survey value is more appropriate 
based on its similarity in the physician work to other diagnostic 
tests. Accordingly, we are proposing an alternative work RVU of 0.80 
for CPT code 78264 for CY 2012.
25. Nasopharyngoscopy
[GRAPHIC] [TIFF OMITTED] TP06JN11.044

    In the Fourth Five-Year Review, we identified CPT code 92511 as 
potentially misvalued through the Harvard-Valued--Utilization > 30,000 
screen.
    For CPT code 92511 (Nasopharyngoscopy with endoscope (separate 
procedure)), the AMA RUC reviewed the survey results of 30 (out of a 
sample size of 100) physicians. The AMA RUC noted that there is 
typically an E/M service furnished on the same day as this service. AMA 
RUC indicated that it believes the survey data overestimated the 
physician work involved in the surveyed code and recommended that for 
CPT code 92511, a direct work RVU crosswalk to CPT code 69210 (Removal 
impacted cerumen (separate procedure), 1 or both ears) was appropriate. 
Accordingly, the AMA RUC recommended a work RVU of 0.61 for CPT code 
92511.
    We agree with the AMA RUC's recommended work RVU and are proposing 
a work RVU of 0.61 for CPT code 92511 for CY 2012. However, while the 
AMA RUC noted that there is typically an E/M service furnished on the 
same day as this service, we are concerned that the times in the 
surveyed code were not adjusted to account for the overlap in times. 
The most currently available Medicare PFS claims data continue to show 
that CPT code 92511 is commonly billed with an E/M visit on the same 
day; therefore, as described in section II.A. of this proposed notice, 
to account for this overlap, we reduced the pre-service evaluation and 
post-service time by one-third. We believe that 4 minutes pre-service 
evaluation time and 3 minutes post-service time accurately reflect the 
time required to conduct the work associated with this service. A 
complete list of CMS time refinements can be found in Table 6.
26. Cardiopulmonary Resuscitation
[GRAPHIC] [TIFF OMITTED] TP06JN11.045


[[Page 32456]]


    In the Fourth Five-Year Review, CMS identified CPT code 92950 as 
potentially misvalued through the Harvard-Valued--Utilization > 30,000 
screen.
    For CPT code 92950 (Cardiopulmonary resuscitation (eg, in cardiac 
arrest)), the AMA RUC reviewed the survey results recommended the 
median survey work RVU of 4.50 for CPT code 92950.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
92950. We recognize that patients that undergo this service are very 
ill; however, we do not believe that the typical patient meets all the 
criteria for the critical care codes. Furthermore, the most currently 
available Medicare PFS claims data show that CPT code 92950 is 
typically performed on the same day as an E/M visit. We believe some of 
the activities conducted during the pre- and post-service times of the 
procedure code and the E/M visit overlap and, therefore, should not be 
counted twice in developing the procedure's work value. As described in 
section II.A. of this proposed notice, to account for this overlap, we 
reduced the pre-service evaluation and post service time by one-third. 
We believe that 1 minute pre-service evaluation time and 20 minutes 
post-service time accurately reflect the time required to conduct the 
work associated with this service. A complete list of CMS time 
refinements can be found in Table 6.
27. Osteopathic Manipulative Treatment
[GRAPHIC] [TIFF OMITTED] TP06JN11.046

BILLING CODE C
    In the Fourth Five-Year Review, we identified CPT codes 98925, 
98928 and 98929 as potentially misvalued through the Harvard-Valued--
Utilization > 30,000 screen. Additionally, the American Osteopathic 
Association identified CPT codes 98926 and 98927 to be reviewed as part 
of this family since these were also identified to be reviewed by the 
AMA RUC Relativity Assessment Workgroup because these codes were 
identified through the Harvard-Valued--Utilization > 100,000 screen.
    For CPT code 98925 (Osteopathic manipulative treatment (OMT); 1-2 
body regions involved), the AMA RUC reviewed the survey results and, 
based on comparisons to reference codes, recommended a work RVU of 0.50 
for CPT code 98925.
    We disagree with the AMA RUC-recommended work RVU of 0.50 for CPT 
code 98925 and believe that a work RVU of 0.46 is more appropriate for 
this service. We are also refining the time associated with this code. 
Recent PFS claims data show that this service is typically performed on 
the same day as an E/M visit. The AMA RUC considered this, and 
determined that the work associated with the pre- and post-service time 
for CPT code 98925 is separate from the work conducted during the E/M 
visit. While we understand that these services have differences, we 
believe some of the activities conducted during the pre- and post-
service times of the osteopathic manipulative treatment code and the E/
M visit overlap and, therefore, should not be counted twice in 
developing the procedure's work value. As described earlier in section 
II.A. of this proposed notice, to account for this overlap, we reduced 
the pre-service evaluation and post-service time by \1/3\. We believe 
that 1 minute of pre-service evaluation time and 2 minutes post-service 
time accurately reflect the time required to conduct the work 
associated with this service.
    In order to determine the appropriate work RVU for this service 
given the time changes, we calculated the value of the extracted time 
and subtracted it from the AMA RUC-recommended work RVU of 0.50. For 
CPT code 98925, we removed a total of 2 minutes from the AMA RUC-
recommended pre- and post-service times, which amounts to the removal 
of .04 of a work RVU, resulting in a work RVU of 0.46. We noted that 70 
percent of the survey respondents indicated that the work of performing 
this service has not changed in the past 5 years (current RVU = 0.45). 
We are proposing an alternative work RVU of 0.46, with refinement in 
time for CPT code 98925 for CY 2012. A complete list of CMS time 
refinements can be found in Table 6.
    For CPT code 98926 (Osteopathic manipulative treatment (OMT); 3-4 
body regions involved), the AMA RUC reviewed the survey results and 
determined that the survey 25th percentile work RVU of 0.75 provides 
the appropriate incremental difference between this CPT code and others 
in the family, considering the additional intra-service time required 
for the additional body regions involved. Therefore, the AMA RUC 
recommended a work RVU of 0.75 for CPT code 98926.
    We disagree with the AMA RUC-recommended work RVU of 0.75 for CPT 
code 98926 and believe that a work RVU of 0.71 is more appropriate for 
this service. We are also refining the time associated with this code. 
Recent PFS claims data show that this service is typically performed on 
the same day as an E/M visit. The AMA RUC considered this, and 
determined that the work associated with the pre- and post-service time 
for CPT code 98926 is separate from the work conducted during the E/M 
visit. While we understand that these services have differences, we 
believe some of the activities conducted during the pre- and post-
service times of the osteopathic manipulative treatment code and the E/
M visit overlap and, therefore, should not be counted twice in 
developing the procedure's work value. As described earlier in section 
II.A. of this proposed notice, to account for this overlap, we reduced 
the pre-service evaluation and post-service time by \1/3\. We believe 
that 1 minute of pre-service evaluation time and 2 minutes post-service 
time accurately reflect the time required to conduct the work 
associated with this service.
    In order to determine the appropriate work RVU for this service 
given the time changes, we calculated the value of the

[[Page 32457]]

extracted time and subtracted it from the AMA RUC-recommended work RVU 
of 0.75. For CPT code 98926, we removed a total of 2 minutes from the 
AMA RUC-recommended pre- and post-service times, which amounts to the 
removal of .04 of a work RVU, resulting in a work RVU of 0.71. We noted 
that 81 percent of the survey respondents indicated that the work of 
performing this service has not changed in the past 5 years (current 
RVU = 0.65). We are proposing an alternative work RVU of 0.71, with 
refinement in time for CPT code 98926 for CY 2012. A complete list of 
CMS time refinements can be found in Table 6.
    For CPT code 98927 (Osteopathic manipulative treatment (OMT); 5-6 
body regions involved), the AMA RUC reviewed the survey results and 
determined that a work RVU of 1.00 provides the appropriate incremental 
difference between this CPT code and others in the family, considering 
the additional intra-service time required for the additional body 
regions involved. The AMA RUC stated that this value is supported by 
the survey 25th percentile work RVU of 0.97. The AMA RUC recommended a 
work RVU of 1.00 for CPT code 98927.
    We disagree with the AMA RUC-recommended work RVU of 1.00 for CPT 
code 98927 and believe that a work RVU of 0.96 is more appropriate for 
this service. We are also refining the time associated with this code. 
Recent PFS claims data show that this service is typically performed on 
the same day as an E/M visit. The AMA RUC considered this, and 
determined that the work associated with the pre- and post-service time 
for CPT code 98927 is separate from the work conducted during the E/M 
visit. While we understand that these services have differences, we 
believe some of the activities conducted during the pre- and post-
service times of the osteopathic manipulative treatment code and the E/
M visit overlap and, therefore, should not be counted twice in 
developing the procedure's work value. As described earlier in section 
II.A. of this proposed notice, to account for this overlap, we reduced 
the pre-service evaluation and post-service time by \1/3\. We believe 
that 1 minute of pre-service evaluation time and 2 minutes post-service 
time accurately reflect the time required to conduct the work 
associated with this service.
    In order to determine the appropriate work RVU for this service 
given the time changes, we calculated the value of the extracted time 
and subtracted it from the AMA RUC-recommended work RVU of 1.00. For 
CPT code 98927, we removed a total of 2 minutes from the AMA RUC-
recommended pre- and post-service times, which amounts to the removal 
of .04 of a work RVU, resulting in a work RVU of 0.96. We noted that 77 
percent of the survey respondents indicated that the work of performing 
this service has not changed in the past 5 years (current RVU = 0.87). 
We are proposing an alternative work RVU of 0.96, with refinement in 
time for CPT code 98927 for CY 2012. A complete list of CMS time 
refinements can be found in Table 6.
    For CPT code 98928 (Osteopathic manipulative treatment (OMT); 7-8 
body regions involved), the AMA RUC reviewed the survey results and 
determined that a work RVU of 1.25 provides the appropriate incremental 
difference between this CPT code and others in the family, considering 
the additional intra-service time required for the additional body 
regions involved. The AMA RUC stated that this value is supported by 
the survey 25th percentile work RVU of 1.29. The AMA RUC recommended a 
work RVU of 1.25 for CPT code 98928.
    We disagree with the AMA RUC-recommended work RVU of 1.25 for CPT 
code 98928 and believe that a work RVU of 1.21 is more appropriate for 
this service. We are also refining the time associated with this code. 
Recent PFS claims data show that this service is typically performed on 
the same day as an E/M visit. The AMA RUC considered this, and 
determined that the work associated with the pre- and post-service time 
for CPT code 98928 is separate from the work conducted during the E/M 
visit. While we understand that these services have differences, we 
believe some of the activities conducted during the pre- and post-
service times of the osteopathic manipulative treatment code and the E/
M visit overlap and, therefore, should not be counted twice in 
developing the procedure's work value. As described earlier in section 
II.A. of this proposed notice, to account for this overlap, we reduced 
the pre-service evaluation and post-service time by \1/3\. We believe 
that 1 minute of pre-service evaluation time and 2 minutes post-service 
time accurately reflect the time required to conduct the work 
associated with this service.
    In order to determine the appropriate work RVU for this service 
given the time changes, we calculated the value of the extracted time 
and subtracted it from the AMA RUC-recommended work RVU of 1.25. For 
CPT code 98928, we removed a total of 2 minutes from the AMA RUC-
recommended pre- and post-service times, which amounts to the removal 
of .04 of a work RVU, resulting in a work RVU of 1.21. We noted that 67 
percent of the survey respondents indicated that the work of performing 
this service has not changed in the past 5 years (current RVU = 1.03). 
We are proposing an alternative work RVU of 1.21, with refinement in 
time for CPT code 98928 for CY 2012. A complete list of CMS time 
refinements can be found in Table 6.
    For CPT code 98929 (Osteopathic manipulative treatment (OMT); 9-10 
body regions involved), the AMA RUC reviewed the survey results and 
determined that the survey 25th percentile work RVU of 1.50 provides 
the appropriate incremental difference between this CPT code and others 
in the family, considering the additional intra-service time required 
for the additional body regions involved. The AMA RUC recommended a 
work RVU of 1.50 for CPT code 98929.
    We disagree with the AMA RUC-recommended work RVU of 1.50 for CPT 
code 98929 and believe that a work RVU of 1.46 is more appropriate for 
this service. We are also refining the time associated with this code. 
Recent PFS claims data show that this service is typically performed on 
the same day as an E/M visit. The AMA RUC considered this, and 
determined that the work associated with the pre- and post-service time 
for CPT code 98929 is separate from the work conducted during the E/M 
visit. While we understand that these services have differences, we 
believe some of the activities conducted during the pre- and post-
service times of the osteopathic manipulative treatment code and the E/
M visit overlap and, therefore, should not be counted twice in 
developing the procedure's work value. As described earlier in section 
II.A. of this proposed notice, to account for this overlap, we reduced 
the pre-service evaluation and post-service time by \1/3\. We believe 
that 1 minute of pre-service evaluation time and 2 minutes post-service 
time accurately reflect the time required to conduct the work 
associated with this service.
    In order to determine the appropriate work RVU for this service 
given the time changes, we calculated the value of the extracted time 
and subtracted it from the AMA RUC-recommended work RVU of 1.50. For 
CPT code 98929, we removed a total of 2 minutes from the AMA RUC-
recommended pre- and post-service times, which amounts to the removal 
of .04 of a work RVU, resulting in a work RVU of 1.46. We noted that 63 
percent of the survey respondents indicated that the work of performing 
this service has not changed in the past

[[Page 32458]]

5 years (current RVU = 1.19). We are proposing an alternative work RVU 
of 1.46, with refinement in time for CPT code 98929 for CY 2012. A 
complete list of CMS time refinements can be found in Table 6.
28. Observation Care
[GRAPHIC] [TIFF OMITTED] TP06JN11.047

    In the Fourth Five-Year Review, CMS identified CPT codes 99218 
through 99220 as potentially misvalued through the Harvard-Valued--
Utilization > 30,000 screen. The American College of Physicians (ACEP) 
also submitted a public comment identifying CPT codes 99218 through 
99220 to be reviewed in the Fourth Five-Year Review. The American 
College of Emergency Physicians (ACEP) also identified CPT codes 99234 
through 99236 as part of the family of services for AMA RUC review.
    For CPT codes 99218 (Level 1 initial observation care, per day), 
99219 (Level 2 initial observation care, per day), and 99220 (Level 3 
initial observation care, per day), the AMA RUC believes that the 
patient population has changed for the initial observation care codes. 
The AMA RUC also believes that a rank order anomaly exists within this 
family of codes as the observation care codes have an analogous 
relationship to the initial hospital care codes (99221 through 99223). 
In October 2009, the AMA RUC considered three new CPT codes for 
subsequent observation care services and recommended a direct crosswalk 
to the corresponding level of subsequent hospital care codes (99231 
through 99233) for the work RVU. The AMA RUC determined that similarly, 
the initial observation codes should be valued equivalently to the 
corresponding initial hospital care codes (99221 through 99223), which 
includes physician times and work RVUs. Accordingly, for CPT codes 
99218-99220, the AMA RUC reviewed the survey results and recommended 
work RVUs of 1.92 for code 99218, 2.60 for code 99219, and 3.56 for 
code 99220 for CY 2012.
    We disagree with the AMA RUC-recommended work RVU for CPT code 
99218, 99219, and 99220. We agree with the AMA RUC that appropriate 
relativity must be maintained within and between the families of 
similar codes. However, we believe that while the work RVUs of these 
initial observation care codes (99218, 99219, and 99220) should be 
greater than those of the subsequent observation care codes (99224, 
99225, and 99226), we do not believe the work RVUs of the initial 
observation care codes (99218, 99219, and 99220) should be equivalent 
(or close) to the initial hospital care codes (99221, 99222, and 
99223). We note that in the CY 2011 PFS final rule with comment period 
(75 FR 73334), we reviewed the new subsequent observation care codes, 
assigning the following work RVUs on an interim final basis for CY 
2011: 0.54 to CPT code 99224, 0.96 to CPT code 99225, and 1.44 to CPT 
code 99226. These are all lower work RVUs than the subsequent hospital 
care codes (99224, 99225, and 99226). Furthermore, we noted that CMS 
has stated previously that in only rare and exceptional cases would 
reasonable and necessary outpatient observation services span more than 
48 hours. In the majority of cases, the decision whether to discharge a 
patient from the hospital following resolution of the reason for the 
observation care or to admit the patient as an inpatient can be made in 
less than 48 hours, usually in less than 24 hours. Consequently, we 
believe that the acuity level of the typical patient receiving 
outpatient observation services would generally be lower than that of 
the inpatient level. We believe that if the patient's acuity level is 
determined to be at the level of the inpatient, the patient should be 
admitted to the hospital as an inpatient. We note that CMS has publicly 
stated in a recent letter to the AHA that ``it is not in the hospital's 
or the beneficiary's interest to extend observation care rather than 
either releasing the patient from the hospital or admitting the patient 
as an inpatient * * *'' (75 FR 73334).
    Consequently, we are not accepting the AMA RUC's recommendation to 
value the initial observation care codes at (for CPT Codes 99218 and 
99219), or close to (for CPT code 99220) the level of initial hospital 
care services. Instead, we believe the work RVUs of the initial 
observation care codes should reflect the modest differences in patient 
acuity between the outpatient and inpatient settings. We compared the 
current work RVUs of the initial observation care codes to the interim 
final work RVUs of the subsequent observation care codes and found that 
the current relativity existing between these codes is acceptable. We 
also believe that the current work RVUs of the initial observation care 
codes maintain the proper rank order with the initial hospital care 
services. Therefore, we are proposing to maintain the following work 
RVUs for the initial observation care codes for CY 2012: 1.28 for CPT 
code 99218, 2.14 for CPT code 99219, and 2.99 for CPT code 99220. We 
note we are accepting the survey median physician times for these 
codes, as recommended by the AMA RUC. A complete list of CMS time 
refinements can be found in Table 6.
    For CPT codes 99234 (Level 1, observation or inpatient hospital 
care, for the evaluation and management of a patient including 
admission and discharge on the same date); 99235 (Level 2, observation 
or inpatient hospital care, for the evaluation and management of a 
patient including admission and discharge on the same date); and 99236 
(Level 3 observation or inpatient hospital care, for the evaluation and 
management of a patient

[[Page 32459]]

including admission and discharge on the same date), the AMA RUC 
reviewed the survey results from 50 internal medicine, family, 
geriatric, and emergency physicians. The specialty societies indicated 
and the AMA RUC agreed that survey results appeared flawed. The 
specialty societies determined that the inability to accurately survey 
the physician time and work required to perform this service was due to 
the fact that observation same day admit/discharge services are 
typically performed by hospitalists (primarily internists) or emergency 
physicians who work in shifts. Therefore, the physician performing the 
admission is typically not the same physician who performs the 
discharge and the survey respondents were not including the physician 
time and work for both parts of the service.
    Consequently, the AMA RUC used a similar methodology as was 
established to value these services in 1997, by taking the 
corresponding initial observation care code of the same level, for 
example, CPT code 99218 (AMA RUC-recommended work RVU = 1.92) plus half 
the value of a hospital discharge day management service, CPT code 
99238 (work RVU = 1.28). Therefore, for CPT code 99234, the AMA RUC 
recommended maintaining the current work RVU of 2.56, as using the 
aforementioned methodology produces the same result. For CPT code 
99235, the AMA RUC used the corresponding initial observation care 
code, CPT code 99219 (AMA RUC-recommended work RVU = 2.6) plus half the 
value of a hospital discharge day management service, CPT code 99238 
(work RVU = 1.28) and recommended the work RVU of 3.24, using the 
aforementioned methodology. Finally, for CPT code 99236, the AMA RUC 
used the corresponding initial observation care code, CPT code 99220 
(AMA RUC-recommended work RVU = 2.6) plus half the value of a hospital 
discharge day management service, CPT code 99238 (work RVU = 1.28) and 
recommended the work RVU of 4.2, using the aforementioned methodology.
    We agree with the AMA RUC's approach to valuing these observation 
same day admit/discharge services; however, we believe that the values 
for CPT codes 99218, 99219, and 99220 that are incorporated should be 
the CMS proposed values discussed above rather than the AMA RUC-
recommended values. Therefore, using the proposed work RVU of 1.28 for 
CPT code 99218 and consistent with the aforementioned methodology, we 
are proposing a work RVU of 1.92 for CPT code 99234 for CY 2012. For 
CPT code 99235, using the proposed work RVU of 2.14 for CPT code 99219 
and applying the methodology, we are proposing a work RVU of 2.78 for 
CY 2012. Finally, using the proposed work RVU of 2.99 for CPT code 
99220 and applying the methodology, we are proposing a work RVU of 3.63 
for CPT code 99236 for CY 2012. We also made corresponding physician 
time changes. A complete list of CMS time refinements can be found in 
Table 6.

D. HCPAC-Recommended Work RVUs

1. Excision of Nail
[GRAPHIC] [TIFF OMITTED] TP06JN11.048

    In the Fourth Five-Year Review, we identified CPT codes 11732 and 
11765 as potentially misvalued through Harvard-Valued--Utilization > 
30,000 screen.
    For CPT code 11723 (Avulsion of nail plate, partial or complete, 
simple; each additional nail plate (List separately in addition to code 
for primary procedure), the HCPAC reviewed the survey data and 
determined that the survey 25th percentile work RVU with total time of 
15 minutes, was appropriate for this service. The HCPAC recommended a 
work RVU of 0.48 for CPT code 11732.
    We disagree with the HCPAC-recommended work RVU for CPT code 11723 
and believe that a work RVU of 0.44 is more appropriate for this 
service. We compared CPT code 11723 to MPC CPT code 92250 and 
determined that CPT 92250 was the more appropriate crosswalk. 
Additionally, we find the HCPAC-recommended decrease in work RVU to be 
too small, given the recommended reduction in time. Therefore, we are 
proposing an alternative work RVU of 0.44 for CPT code 11723 for CY 
2012.
    In addition to the work RVU adjustment for CPT code 11723, CMS is 
refining the time associated with this code. While we agree with the 
stated rationale justifying the 2 minutes pre-service time, we find the 
recommended 3 minutes post-service time to be excessive. Upon clinical 
review, we believe that 1 minute post-service time more accurately 
reflects the time required to conduct the post-service work associated 
with this service. A complete list of CMS time refinements can be found 
in Table 6.
    For CPT code 11765 (Wedge excision of skin of nail fold (e.g., for 
ingrown toenail)), the HCPAC reviewed the survey results and determined 
that the survey median work RVU with total time of 59 minutes was 
appropriate for this service. The HCPAC recommended a work RVU of 1.48 
for CPT code 11765.
    We disagree with the HCPAC-recommended work RVU for CPT code 11765 
and believe that a work RVU of 1.22 is more appropriate. We compared 
CPT code 11765 with reference CPT code 11422, as well as with CPT code 
10060 (Incision and drainage of abscess (e.g., carbuncle, suppurative 
hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or 
paronychia); simple or single) (work RVU = 1.22), and determined that 
CPT code 10060 was more similar in intensity and complexity to CPT code 
11765, and thus the better comparator code for this service. Therefore, 
we are proposing an alternative work RVU of 1.22 for CPT code 11765.
    In addition to the work RVU adjustment for CPT code 11765, CMS is 
refining the time associated with this code. This service is typically 
performed on the same day as an E/M visit. We believe some of the 
activities conducted during the pre- and post-service times of the 
procedure code and the E/M visit overlap and, therefore, should not be 
counted twice in developing the procedure's work value. As described in 
section II.A. of this proposed notice, to account for this overlap, we 
reduced the pre-service evaluation and post-service time by one-

[[Page 32460]]

third. We believe that 11 minutes pre-service evaluation time and 3 
minutes post-service time accurately reflect the time required to 
conduct the work associated with this service. A complete list of CMS 
time refinements can be found in Table 6.

E. CPT Codes Identified Through the Five-Year Review Process, but Not 
Reviewed by CMS

1. CPT Codes Referred to CPT Editorial Panel
    The following table lists the CPT codes that were subsequently sent 
to the CPT Editorial Panel to consider coding changes. Therefore, the 
work RVUs for these codes are not addressed in this Five-Year Review 
proposed notice.
BILLING CODE P

[[Page 32461]]

[GRAPHIC] [TIFF OMITTED] TP06JN11.049


[[Page 32462]]


2. CPT Codes Withdrawn From the Five-Year Review
    The following table lists the CPT codes that were subsequently 
withdrawn from the Five-Year Review at the request of the medical 
specialty societies who submitted the codes for review in their public 
comments on the CY 2010 PFS final rule with comment period and with the 
agreement of the AMA RUC. Therefore, the work RVUs for these codes are 
not addressed in this Five-Year Review proposed notice.
[GRAPHIC] [TIFF OMITTED] TP06JN11.050

3. CPT Codes That Are Interim Final for CY 2011
    The following table lists the CPT codes that were identified by CMS 
through the Five-Year Review process, but were recently addressed in 
the CY 2011 PFS final rule with comment period. The RVUs for these 
codes are currently interim final in CY 2011, were subject to public 
comment on the CY 2011 PFS final rule with comment period, and will be 
finalized in the CY 2012 PFS final rule with comment period. Two CPT 
codes on this list, 11040 and 11041, were deleted by the CPT Editorial 
Panel for CY 2011 and replaced by new CPT codes on this list (11042 
through 11047). Therefore, the work RVUs for these codes are not 
addressed in this Five-Year Review proposed notice.

[[Page 32463]]

[GRAPHIC] [TIFF OMITTED] TP06JN11.051

4. CPT Codes for Preventive Medicine Services
    The following table lists the CPT codes that were identified 
through the Five-Year Review process by commenters on the CY 2010 PFS 
final rule with comment period, but are preventive medicine services 
not covered by Medicare under the PFS. The AMA RUC-recommended RVUs 
associated with these codes are published in Addendum B of this 
proposed notice for public reference, but have not been reviewed by 
CMS. Therefore, the work RVUs for these codes are not addressed in this 
Five-Year Review proposed notice. We note that Medicare covers a range 
of preventive services, including the initial preventive physical 
examination (IPPE) (``Welcome to Medicare Visit'') and the annual 
wellness visit (AWV), as detailed in the PFS CY 2011 final rule with 
comment period (75 FR 73412).

[[Page 32464]]

[GRAPHIC] [TIFF OMITTED] TP06JN11.052

BILLING CODE C

F. Resource-Based Practice Expense RVUs

1. Overview
    Practice expense (PE) is the portion of the resources used in 
furnishing the service that reflects the general categories of 
physician and practitioner expenses, such as office rent and personnel 
wages but excluding malpractice expenses, as specified in section 
1848(c)(1)(B) of the Act. Section 121 of the Social Security Amendments 
of 1994 (Pub. L. 103-432), enacted on October 31, 1994, required us to 
develop a methodology for a resource-based system for determining PE 
RVUs for each physician's service.
    This proposed notice sets forth proposed revisions to work RVUs 
affecting payment for physicians' services. PE RVUs were not subject to 
similar review. However, the proposed work RVU changes will have an 
impact on the development of PE RVUs due to the methodology we use to 
develop PE RVUs by looking at the direct and indirect physician 
practice resources involved in furnishing each service. Changes in work 
RVUs, changes in the intra-service portions of the physician time, and 
changes in the number or level of postoperative evaluation and 
management (E/M) visits associated with these services and their global 
periods result in corresponding changes to the direct PE inputs and 
other components used in the development of PE RVUs.
    The sections that follow provide more detailed information about 
the methodology for translating the resources involved in furnishing 
each service into service-specific PE RVUs and the ways in which the 
revisions set forth in this proposed notice alter some of the inputs 
used in that methodology. We also refer readers to the CY 2010 PFS 
final rule with comment period (74 FR 61743 through 61748) for a more 
detailed review of the PE methodology, including examples.
2. Practice Expense Methodology
a. Direct Practice Expense
    We use a ``bottom-up'' approach to determine the direct PE by 
adding the costs of the resources (that is, the clinical staff, 
equipment, and supplies) typically involved in furnishing each service. 
The costs of the resources are calculated using the refined direct PE 
inputs assigned to each CPT code in our PE database, which are based on 
our review of recommendations received from the American Medical 
Association's (AMA's) Relative Value Update Committee (RUC). For a 
detailed explanation of the bottom-up direct PE methodology, including 
examples, we refer readers to the Five-Year Review of Work Relative 
Value Units Under the PFS and Proposed Changes to the Practice Expense 
Methodology proposed notice (71 FR 37242) and the CY 2007 PFS final 
rule with comment period (71 FR 69629).
b. Indirect Practice Expense per Hour Data
    We use survey data on indirect practice expenses incurred per hour 
worked (PE/HR) in developing the indirect portion of the PE RVUs. Prior 
to CY 2010, we primarily used the practice expense per hour (PE/HR) by 
specialty that was obtained from the AMA's Socioeconomic Monitoring 
Surveys (SMS). The AMA administered a new survey in CY 2007 and CY 
2008, the Physician Practice Expense Information Survey (PPIS), which 
was expanded (relative to the SMS) to include nonphysician 
practitioners (NPPs) paid under the PFS.
    The PPIS is a multispecialty, nationally representative, PE survey 
of both physicians and NPPs using a consistent survey instrument and 
methods highly consistent with those used for the SMS and the 
supplemental surveys. The PPIS gathered information from 3,656 
respondents across 51 physician specialty and healthcare professional 
groups. We believe the PPIS is the most comprehensive source of PE 
survey information available to date. Therefore, we used the PPIS data 
to update the PE/HR data for almost all of the Medicare-recognized 
specialties that participated in the survey for the CY 2010 PFS.
    When we changed over to the PPIS data beginning in CY 2010, we did 
not change the PE RVU methodology itself or the manner in which the PE/
HR data are used in that methodology. We only updated the PE/HR data 
based on the new survey. Furthermore, as we explained in the CY 2010 
PFS final rule with comment period (74 FR 61751), because of the 
magnitude of payment reductions for some specialties resulting from the 
use of the PPIS data, we finalized a 4-year transition (75 percent old/
25 percent new for CY 2010, 50 percent old/50 percent new for CY 2011, 
25 percent old/75 percent new for CY 2012, and 100 percent new for CY 
2013) from the previous PE RVUs to the PE RVUs developed using the new 
PPIS data.
    Section 303 of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA) (Pub. L. 108-173) added section 
1848(c)(2)(H)(i) of the Act, which requires us to use the medical 
oncology

[[Page 32465]]

supplemental survey data submitted in 2003 for oncology drug 
administration services. Therefore, the PE/HR for medical oncology, 
hematology, and hematology/oncology reflects the continued use of these 
supplemental survey data.
    We do not use the PPIS data for reproductive endocrinology, sleep 
medicine, and spine surgery since these specialties are not separately 
recognized by Medicare, nor do we have a method to blend these data 
with Medicare-recognized specialty data.
    Supplemental survey data on independent labs, from the College of 
American Pathologists, were implemented for payments in CY 2005. 
Supplemental survey data from the National Coalition of Quality 
Diagnostic Imaging Services (NCQDIS), representing independent 
diagnostic testing facilities (IDTFs), were blended with supplementary 
survey data from the American College of Radiology (ACR) and 
implemented for payments in CY 2007. Neither IDTFs nor independent labs 
participated in the PPIS. Therefore, we continue to use the PE/HR that 
was developed from their supplemental survey data.
    Consistent with our past practice, the previous indirect PE/HR 
values from the supplemental surveys for medical oncology, independent 
laboratories, and IDTFs were updated to CY 2006 using the MEI to put 
them on a comparable basis with the PPIS data.
    Previously, we have established PE/HR values for certain 
specialties without SMS or supplemental survey data by cross-walking 
them to other similar specialties to estimate a proxy PE/HR. For 
specialties that were part of the PPIS for which we previously used a 
crosswalked PE/HR, we instead use the PPIS-based PE/HR. We continue to 
use the previous crosswalks for specialties that did not participate in 
the PPIS. However, beginning in CY 2010 we changed the PE/HR crosswalk 
for portable x-ray suppliers from radiology to IDTF, a more appropriate 
crosswalk because these specialties are more similar to each other with 
respect to physician time.
    For registered dietician services, the proposed resource-based PE 
RVUs have been calculated in accordance with the final policy that 
crosswalks the specialty to the ``All Physicians'' PE/HR data, as 
adopted in the CY 2010 PFS final rule with comment period (74 FR 61752) 
and discussed again in more detail in the CY 2011 PFS final rule with 
comment period (75 FR 73183).
    As provided in the CY 2010 PFS final rule with comment period (74 
FR 61751), CY 2012 is the third year of the 4 year transition to the PE 
RVUs calculated using the PPIS data. Therefore, in general, the CY 2012 
PE RVUs are a 25 percent/75 percent blend of the previous PE RVUs based 
on the SMS and supplemental survey data and the new PE RVUS developed 
using the PPIS data as described above. Note that the reductions in the 
PE RVUs for expensive diagnostic imaging equipment attributable to the 
change in the equipment utilization rate assumption to 75 percent are 
not subject to the transition, as discussed in the CY 2011 PFS final 
rule with comment period (75 FR 73189 through 73192).
    Additionally, the PPIS PE RVU transition will not apply to CPT 
codes with changes in global periods. As discussed in the CY 2011 PFS 
final rule with comment period (75 FR 73183), we believe that a change 
in the global period of a code results in the CPT code describing a 
different service to which the previous PE RVUs would no longer be 
relevant when the code is reported for a service furnished with the new 
global period. The two CPT codes with proposed changes in global period 
for CY 2012 are: 51705 (Change of cystostomy tube; simple) and 51710 
(Change of cystostomy tube; complicated). The global period for each of 
these codes changed from a 10-day to a 0-day global period.
c. Allocation of Practice Expense to Services
    To establish PE RVUs for specific services, it is necessary to 
establish the direct and indirect PE associated with each service.
(1) Direct Costs
    The relative relationship between the direct cost portions of the 
PE RVUs for any two services is determined by the relative relationship 
between the sum of the direct cost resources (that is, the clinical 
staff, equipment, and supplies) typically required to provide the 
services. The costs of these resources are calculated from the refined 
direct PE inputs in our PE database. For example, if one service has a 
direct PE input cost sum of $400 and another service has a direct PE 
input cost sum of $200, the direct portion of the PE RVUs of the first 
service would be twice as much as the direct portion of the PE RVUs for 
the second service.
(2) Indirect Costs
    Section II.F.2.b. of this proposed notice describes the current 
data sources for specialty-specific indirect costs used in our PE 
calculations. We allocate the indirect costs to the code level on the 
basis of the direct costs specifically associated with a code and the 
greater of either the clinical labor costs or the physician work RVUs. 
We also incorporate the survey data described earlier in the PE/HR 
discussion. The general approach to developing the indirect portion of 
the PE RVUs is described below.
     For a given service, we use the direct portion of the PE 
RVUs calculated as described above and the average percentage that 
direct costs represent of total costs (based on survey data) across the 
specialties that perform the service to determine an initial indirect 
allocator. For example, if the direct portion of the PE RVUs for a 
given service were 2.00 and direct costs, on average, represented 25 
percent of total costs for the specialties that performed the service, 
the initial indirect allocator would be 6.00 since 2.00 is 25 percent 
of 8.00.
     We then add the greater of the work RVUs or clinical labor 
portion of the direct portion of the PE RVUs to this initial indirect 
allocator. In our example, if this service had work RVUs of 4.00 and 
the clinical labor portion of the direct PE RVUs was 1.50, we would add 
6.00 plus 4.00 (since the 4.00 work RVUs are greater than the 1.50 
clinical labor portion) to get an indirect allocator of 10.00. In the 
absence of any further use of the survey data, the relative 
relationship between the indirect cost portions of the PE RVUs for any 
two services would be determined by the relative relationship between 
these indirect cost allocators. For example, if one service had an 
indirect cost allocator of 10.00 and another service had an indirect 
cost allocator of 5.00, the indirect portion of the PE RVUs of the 
first service would be twice as great as the indirect portion of the PE 
RVUs for the second service.
     We next incorporate the specialty-specific indirect PE/HR 
data into the calculation. As a relatively extreme example for the sake 
of simplicity, assume in our example above that, based on the survey 
data, the average indirect cost of the specialties performing the first 
service with an allocator of 10.00 was half of the average indirect 
cost of the specialties performing the second service with an indirect 
allocator of 5.00. In this case, the indirect portion of the PE RVUs of 
the first service would be equal to that of the second service.
d. Facility and Nonfacility Costs
    For procedures that can be furnished in a physician's office, as 
well as in a hospital or other facility setting, we establish two PE 
RVUs: Facility and nonfacility. The methodology for

[[Page 32466]]

calculating PE RVUs is the same for both the facility and nonfacility 
RVUs, but is applied independently to yield two separate PE RVUs. 
Because Medicare makes a separate payment to the facility for its costs 
of furnishing a service, the facility PE RVUs are generally lower than 
the nonfacility PE RVUs.
e. Services With Technical Components and Professional Components
    Diagnostic services are generally comprised of two components, a 
professional component (PC) and a technical component (TC), each of 
which may be performed independently by different providers, or they 
may be performed together as a ``global'' service. When services have 
PC and TC components that can be billed separately, the payment for the 
global component equals the sum of the payment for the TC and PC. This 
is a result of using a weighted average of the ratio of indirect to 
direct costs across all the specialties that furnish the global 
components, TCs, and PCs; that is, we apply the same weighted average 
indirect percentage factor to allocate indirect expenses to the global 
components, PCs, and TCs for a service. (The direct PE RVUs for the TC 
and PC sum to the global under the bottom-up methodology.)
f. Practice Expense RVU Methodology
    For a more detailed description of the PE RVU methodology, we refer 
readers to the CY 2010 PFS final rule with comment period (74 FR 61745 
through 61746).
(1) Setup File
    First, we create a setup file for the PE methodology. The setup 
file contains the direct cost inputs, the utilization for each 
procedure code at the specialty and facility/nonfacility place of 
service level, and the specialty-specific PE/HR data from the surveys.
(2) Calculate the Direct Cost PE RVUs
    Sum the costs of each direct input as follows:
     Step 1: Sum the direct costs of the inputs for each 
service.
    Apply a scaling adjustment to the direct inputs.
     Step 2: Calculate the current aggregate pool of direct PE 
costs. This is the product of the current aggregate PE (aggregate 
direct and indirect) RVUs, the CF, and the average direct PE percentage 
from the survey data.
     Step 3: Calculate the aggregate pool of direct costs. This 
is the sum of the product of the direct costs for each service from 
Step 1 and the utilization data for that service.
     Step 4: Using the results of Step 2 and Step 3 calculate a 
direct PE scaling adjustment so that the aggregate direct cost pool 
does not exceed the current aggregate direct cost pool and apply it to 
the direct costs from Step 1 for each service.
     Step 5: Convert the results of Step 4 to an RVU scale for 
each service. To do this, divide the results of Step 4 by the CF. Note 
that the actual value of the CF used in this calculation does not 
influence the final direct cost PE RVUs, as long as the same CF is used 
in Steps 2 and 5. Different CFs will result in different direct PE 
scaling factors, but this has no effect on the final direct cost PE 
RVUs since changes in the CFs and changes in the associated direct 
scaling factors offset one another.
(3) Create the Indirect Cost PE RVUs
    Create indirect allocators as follows:
     Step 6: Based on the survey data, calculate direct and 
indirect PE percentages for each physician specialty.
     Step 7: Calculate direct and indirect PE percentages at 
the service level by taking a weighted average of the results of Step 6 
for the specialties that furnish the service. Note that for services 
with TCs and PCs, the direct and indirect percentages for a given 
service do not vary by the PC, TC, and global components.
     Step 8: Calculate the service level allocators for the 
indirect PE RVUs based on the percentages calculated in Step 7. The 
indirect PE RVUs are allocated based on the three components: The 
direct PE RVUs, the clinical PE RVUs, and the work RVUs. For most 
services the indirect allocator is: Indirect percentage * (direct PE 
RVUs/direct percentage) + work RVUs.
    There are two situations where this formula is modified as follows:
     If the service is a global service (that is, a service 
with global, professional, and technical components), then the indirect 
allocator is: Indirect percentage (direct PE RVUs/direct percentage) + 
clinical PE RVUs + work RVUs.
     If the clinical labor PE RVUs exceed the work RVUs (and 
the service is not a global service), then the indirect allocator is: 
Indirect percentage (direct PE RVUs/direct percentage) + clinical PE 
RVUs.

    (Note: For global services, the indirect allocator is based on 
both the work RVUs and the clinical labor PE RVUs. We do this to 
recognize that, for the PC service, indirect PEs will be allocated 
using the work RVUs, and for the TC service, indirect PEs will be 
allocated using the direct PE RVUs and the clinical labor PE RVUs. 
This also allows the global component RVUs to equal the sum of the 
PC and TC RVUs.)

    Apply a scaling adjustment to the indirect allocators.
     Step 9: Calculate the current aggregate pool of indirect 
PE RVUs by multiplying the current aggregate pool of PE RVUs by the 
average indirect PE percentage from the survey data.
     Step 10: Calculate an aggregate pool of indirect PE RVUs 
for all PFS services by adding the product of the indirect PE 
allocators for a service from Step 8 and the utilization data for that 
service.
     Step 11: Using the results of Step 9 and Step 10, 
calculate an indirect PE adjustment so that the aggregate indirect 
allocation does not exceed the available aggregate indirect PE RVUs and 
apply it to indirect allocators calculated in Step 8. Calculate the 
indirect practice cost index.
     Step 12: Using the results of Step 11, calculate aggregate 
pools of specialty-specific adjusted indirect PE allocators for all PFS 
services for a specialty by adding the product of the adjusted indirect 
PE allocator for each service and the utilization data for that 
service.
     Step 13: Using the specialty-specific indirect PE/HR data, 
calculate specialty-specific aggregate pools of indirect PE for all PFS 
services for that specialty by adding the product of the indirect PE/HR 
for the specialty, the physician time for the service, and the 
specialty's utilization for the service across all services performed 
by the specialty.
     Step 14: Using the results of Step 12 and Step 13, 
calculate the specialty-specific indirect PE scaling factors.
     Step 15: Using the results of Step 14, calculate an 
indirect practice cost index at the specialty level by dividing each 
specialty-specific indirect scaling factor by the average indirect 
scaling factor for the entire PFS.
     Step 16: Calculate the indirect practice cost index at the 
service level to ensure the capture of all indirect costs. Calculate a 
weighted average of the practice cost index values for the specialties 
that furnish the service. (Note: For services with TCs and PCs, we 
calculate the indirect practice cost index across the global 
components, PCs, and TCs. Under this method, the indirect practice cost 
index for a given service (for example, echocardiogram) does not vary 
by the PC, TC, and global component.)
     Step 17: Apply the service level indirect practice cost 
index calculated in Step 16 to the service level adjusted indirect 
allocators calculated in Step 11 to get the indirect PE RVUs.

[[Page 32467]]

(4) Calculate the Final PE RVUs
     Step 18: Add the direct PE RVUs from Step 6 to the 
indirect PE RVUs from Step 17 and apply the final PE budget neutrality 
(BN) adjustment.
    The final PE BN adjustment is calculated by comparing the results 
of Step 18 to the current pool of PE RVUs. This final BN adjustment is 
required primarily because certain specialties are excluded from the PE 
RVU calculation for ratesetting purposes, but all specialties are 
included for purposes of calculating the final BN adjustment. (See 
``Specialties excluded from ratesetting calculation'' in this section.)
(5) Setup File Information
    Specialties excluded from ratesetting calculation: For the purposes 
of calculating the PE RVUs, we exclude certain specialties, such as 
certain nonphysician practitioners paid at a percentage of the PFS and 
low-volume specialties, from the calculation. These specialties are 
included for the purposes of calculating the BN adjustment. They are 
displayed in Table 7.
[GRAPHIC] [TIFF OMITTED] TP06JN11.053


[[Page 32468]]


     Crosswalk certain low volume physician specialties: 
Crosswalk the utilization of certain specialties with relatively low 
PFS utilization to the associated specialties.
     Physical therapy utilization: Crosswalk the utilization 
associated with all physical therapy services to the specialty of 
physical therapy.
     Identify professional and technical services not 
identified under the usual TC and 26 modifiers: Flag the services that 
are PC and TC services, but do not use TC and 26 modifiers (for 
example, electrocardiograms). This flag associates the PC and TC with 
the associated global code for use in creating the indirect PE RVUs. 
For example, the professional service, CPT code 93010 
(Electrocardiogram, routine ECG with at least 12 leads; interpretation 
and report only), is associated with the global service, CPT code 93000 
(Electrocardiogram, routine ECG with at least 12 leads; with 
interpretation and report).
     Payment modifiers: Payment modifiers are accounted for in 
the creation of the file. For example, services billed with the 
assistant at surgery modifier are paid 16 percent of the PFS amount for 
that service; therefore, the utilization file is modified to only 
account for 16 percent of any service that contains the assistant at 
surgery modifier.
     Work RVUs: The setup file contains the work RVUs from this 
proposed notice.
(6) Equipment Cost per Minute
    The equipment cost per minute is calculated as:

(1/(minutes per year * usage)) * price * ((interest rate/(1-(1/((1 + 
interest rate)- life of equipment)))) + maintenance)

Where:

Minutes per year = maximum minutes per year if usage were continuous 
(that is, usage = 1); generally 150,000 minutes.
Usage = equipment utilization assumption; 0.75 for certain expensive 
diagnostic imaging equipment (see 75 FR 73189 through 73192) and 0.5 
for others.
Price = price of the particular piece of equipment.
Interest rate = 0.11.
Life of equipment = useful life of the particular piece of 
equipment.
Maintenance = factor for maintenance; 0.05.
3. Practice Expense RVUs for Codes Included in the Five-Year Review
    Some direct PE inputs and other components of the PE methodology 
are directly affected by the proposed revisions in work RVUs and 
physician time described in section II.C. of this proposed notice. In 
the following discussion, we detail how changes in work RVUs, changes 
in the intra-service portions of the physician time, and changes in the 
number or level of postoperative visits associated with the global 
periods result in corresponding changes to direct PE inputs and other 
components used in the development of PE RVUs.
a. Changes to Direct Practice Expense Inputs
    Proposed changes in the intra-service portions of the physician 
time, and in the number or level of postoperative visits within the 
global periods associated with particular codes, result in 
corresponding changes in the values of certain direct PE inputs 
(clinical labor time, equipment time, and supply quantity). The 
following sections present the logic we used in making changes in the 
direct PE inputs based on their association with physician time. These 
changes are included in the Five-Year Review of Work proposed notice 
direct PE database, which is available on the CMS Web site under the 
downloads for this proposed notice at: http://www.cms.gov/PhysicianFeeSched/.
(1) Changes in Intra-service Physician Time in the Nonfacility Setting
    Clinical Labor: For most codes valued in the nonfacility setting, a 
portion of the clinical labor time allocated to the intra-service 
period reflects minutes assigned for assisting the physician with the 
procedure. To the extent that we are proposing changes in the times 
associated with the intra-service portion of such procedures, we have 
adjusted the corresponding intra-service clinical labor minutes in the 
nonfacility setting.
    Equipment Time: For equipment associated with the intra-service 
period in the nonfacility setting, we generally allocate time based on 
the typical number of minutes a piece of equipment is being used and, 
therefore, not available for use with another patient during that 
period. In general, we allocate these minutes based on the description 
of typical clinical labor activities. To the extent that we are 
proposing changes in the clinical labor times associated with the 
intra-service portion of procedures, we have adjusted the corresponding 
equipment minutes associated with the codes.
(2) Changes in Hospital Discharge Management Services in the Facility 
Setting
    Clinical Labor: For most codes with 10 or 90 day global periods 
that are valued in the facility setting, a portion of the clinical 
labor time allocated to the intra-service period in the facility 
setting reflects minutes assigned for discharge day management. To the 
extent that we are proposing changes in the physician times associated 
with hospital discharge day management, we have adjusted the 
corresponding intra-service clinical labor minutes in the facility 
setting.
(3) Changes in the Number or Level of Postoperative Office Visits in 
the Global Period
    Clinical Labor: For codes valued with post-service physician office 
visits during a global period, most of the clinical labor time 
allocated to the post-service period reflects a standard number of 
minutes allocated for each of those visits. To the extent that we are 
proposing a change in the number or level of postoperative visits, we 
have modified the clinical staff time in the post-service period to 
reflect the change.
    Equipment Time: For codes valued with post-service physician office 
visits during a global period, we allocate standard equipment for each 
of those visits. To the extent that we are proposing a change in the 
number or level of postoperative visits associated with a code, we have 
adjusted the corresponding equipment minutes.
    Supplies: For codes valued with post-service physician office 
visits during a global period, a certain number of supply items are 
allocated for each of those office visits. To the extent that we are 
proposing a change in the number of postoperative visits, we have 
adjusted the corresponding supply item quantities associated with the 
codes. We note that many supply items associated with post-service 
physician office visits are allocated for each office visit (for 
example, a minimum multi-specialty visit pack (SA048) in the proposed 
notice direct PE database). For these supply items, the quantities in 
the proposed notice direct PE database should reflect the proposed 
number of office visits associated with the code's global period. 
However, some supply items are associated with post-service physician 
office visits but are only allocated once during the global period 
because they are typically used during only one of the post-service 
office visits (for example, pack, post-op incision care (suture) 
(SA054) in the proposed notice direct PE database). For these supply 
items, the quantities in the proposed notice direct PE database reflect 
that single quantity.

[[Page 32469]]

b. Changes in Components of the Indirect Practice Expense Methodology
(1) Work RVUs, Direct PE RVUs, and Clinical Labor PE RVUs
    In calculating the allocations for indirect PE RVUs, as we describe 
in section II.F.2.f. of this proposed notice, we calculate the service 
level allocators for the indirect PEs based on the three components: 
direct PE RVUs, clinical labor PE RVUs, and work RVUs. Therefore, 
changes in the values of those components result in corresponding 
changes in the allocation of indirect PE RVUs.
(2) Physician Time
    Similarly, in creating the indirect practice cost index, as we 
describe in section II.F.2.f. of this proposed notice, we calculate 
specialty-specific aggregate pools of indirect PE for all PFS services 
for that specialty by adding the product of the indirect PE/HR for the 
specialty, the physician time for the service, and the specialty's 
utilization for the service across all services performed by the 
specialty. Therefore, changes in the physician time result in 
corresponding changes in the calculation of specialty-specific 
aggregate pools of indirect PE for all PFS services for that specialty 
and consequently, the allocation of indirect PE RVUs.

G. Malpractice RVUs

    Section 1848(c) of the Act requires that each service paid under 
the PFS be comprised of three components: Work, PE, and malpractice. 
From 1992 to 1999, malpractice RVUs were charge-based, using weighted 
specialty-specific malpractice expense percentages and 1991 average 
allowed charges. Malpractice RVUs for new codes after 1991 were 
extrapolated from similar existing codes or as a percentage of the 
corresponding work RVU. Section 1848(c)(2)(C)(iii) of the Act required 
us to implement resource-based malpractice RVUs for services furnished 
beginning in 2000. Therefore, initial implementation of resource-based 
malpractice RVUs occurred in 2000.
    The statute also requires that we review, and if necessary adjust, 
RVUs no less often than every 5 years. The first review and update of 
resource-based malpractice RVUs was addressed in the CY 2005 PFS final 
rule with comment period (69 FR 66263). Minor modifications to the 
methodology were addressed in the CY 2006 PFS final rule with comment 
period (70 FR 70153). In the CY 2010 PFS final rule with comment 
period, we implemented the second review and update of malpractice 
RVUs. For a discussion of the second review and update of malpractice 
RVUs, see the CY 2010 PFS proposed rule (74 FR 33537) and final rule 
with comment period (74 FR 61758).
    As established in the CY 2011 PFS final rule with comment period 
(75 FR 73208), malpractice RVUs for new and revised codes effective 
before the next Five-Year Review (for example, effective CY 2011 
through CY 2014) are determined by a direct crosswalk to a similar 
``source'' code or a modified crosswalk to account for differences in 
work RVU between the new/revised code and the source code. For the 
modified crosswalk approach, we adjust the malpractice RVU for the new/
revised code to reflect the difference in work RVU between the source 
code and the new/revised work value (or, if greater, the clinical labor 
portion of the fully implemented PE RVU) for the new code. For example, 
if the proposed work RVU for a revised code is 10 percent higher than 
the work RVU for its source code, the malpractice RVU for the revised 
code would be increased by 10 percent over the source code RVU. This 
approach presumes the same risk factor for the new/revised code and 
source code but uses the work RVU for the new/revised code to adjust 
for risk-of-service. The assigned malpractice RVUs for new/revised 
codes effective between updates remain in place until the next Five-
Year Review. For this Fourth Five-Year Review, with the exception of 3 
CPT codes (33981, 33982, and 33983), the source code for each code 
reviewed in the Five-Year Review is the code itself. Under this usual 
circumstance, we calculated the revised malpractice RVU for these codes 
by scaling the current malpractice RVU by the percent difference in 
work RVU between the current (CY 2011) work RVU and the work RVU 
proposed in section II.C. of this proposed notice.
    CPT codes 33981 (Replacement of extracorporeal ventricular assist 
device, single or biventricular, pump(s), single or each pump); 33982 
(Replacement of ventricular assist device pump(s); implantable 
intracorporeal, single ventricle, without cardiopulmonary bypass); and 
33983 (Replacement of ventricular assist device pump(s); implantable 
intracorporeal, single ventricle, with cardiopulmonary bypass) were 
previously contractor-priced and do not have current work RVUs. 
Therefore we applied the AMA RUC-recommended crosswalks to obtain the 
appropriate malpractice RVUs. The crosswalk source code for CPT code 
33981 is CPT code 33976 (Insertion of ventricular assist device; 
extracorporeal, biventricular), and the crosswalk source for CPT code 
33982 and 33983 is CPT code 33979 (Insertion of ventricular assist 
device, implantable intracorporeal, single ventricle). Consistent with 
the methodology described above, the malpractice RVUs for these three 
newly-valued codes were developed by adjusting the malpractice RVU of 
the source code for the difference in work RVU between the source code 
and the newly-valued code. All malpractice RVUs are listed in Addendum 
B of this proposed notice.

H. Budget Neutrality

    Section 1848(c)(2)(B)(ii) of the Act requires that increases or 
decreases in RVUs for a year may not cause the amount of expenditures 
for the year to differ by more than $20 million from what expenditures 
would have been in the absence of these changes. If this threshold is 
exceeded, we must make adjustments to preserve budget neutrality. We 
estimate that the net effect on the PFS overall from the Fourth Five-
Year Review changes discussed in this proposed notice would be under 
$20 million for CY 2012, as compared to CY 2011, based on CY 2009 
Medicare PFS utilization data. The current law estimate of the CY 2012 
CF is $23.9396. Since the net impact on the PFS is under the $20 
million threshold, we will not apply a budget neutrality adjustment to 
the CY 2012 conversion factor (CF). We note that additional changes to 
PFS payment policies, including the establishment of interim and final 
RVUs for coding changes that will be announced later this year, may 
result in the application of budget-neutrality adjustments for CY 2012.

III. 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 received by 
the date and time specified in the DATES section of this preamble, and 
we will respond to the comments in the CY 2012 PFS final rule with 
comment period.

IV. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35)

[[Page 32470]]

V. Regulatory Impact Analysis

A. Overall Impact

    We have examined the impact of this rule as required by Executive 
Order 12866 on Regulatory Planning and Review (September 30, 1993), 
Executive Order 13563 on Improving Regulation and Regulatory Review 
(February 2, 2011), the Regulatory Flexibility Act (RFA) (September 19, 
1980, Pub. L. 96-354), section 1102(b) of the Act, section 202 of the 
Unfunded Mandates Reform Act of 1995 (March 22, 1995; Pub. L. 104-4), 
Executive Order 13132 on Federalism (August 4, 1999) and the 
Congressional Review Act (5 U.S.C. 804(2)).
    Executive Orders 12866 and 13563 direct 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 must be prepared for major rules with 
economically significant effects ($100 million or more in any 1 year). 
We estimate that this proposed notice will redistribute less than $100 
million of PFS expenditures in 1 year. Therefore, we estimate that this 
rulemaking is not ``economically significant'' as measured by the $100 
million threshold, and hence not a major rule under the Congressional 
Review Act. Accordingly, we are not including a formal regulatory 
impact analysis.
    While we are not including a formal regulatory impact analysis, we 
are providing the following discussion for informational purposes. Of 
the CPT codes reviewed during the Fourth Five-Year Review of Work, 
there are both proposed increases and decreases in work values and 
changes in physician time. The changes in work values and physician 
time values result in corresponding changes to the PE and malpractice 
RVUs, as discussed in sections II.F.3. and II.G. of this proposed 
notice. Overall, we estimate that the net effect on PFS spending would 
be under $20 million for CY 2012, as compared to CY 2011. At the 
specialty level, this Five-Year Review of Work is estimated to have no 
significant impact based on the aggregate services that each specialty 
performed during CY 2009. We note that CY 2009 is the most recent year 
for which complete PFS utilization data are available at the time of 
the analysis for this proposed notice.
    The RFA requires agencies to analyze options for regulatory relief 
of small entities, if a rule has a significant impact on a substantial 
number of small entities. The great majority of hospitals and most 
other health care providers and suppliers are small entities, either by 
being nonprofit organizations or by meeting the SBA definition of a 
small business (having revenues of less than $7.0 million to $34.5 
million in any 1 year). For purposes of the RFA, physicians, 
nonphysician practitioners (NPPs), and other suppliers, including 
independent diagnostic testing facilities (IDTFs), are considered small 
businesses if they generate revenues of $10 million or less based on 
SBA size standards. Approximately 95 percent of physicians are 
considered to be small entities. There are over 1 million physicians, 
other practitioners, and medical suppliers that receive Medicare 
payment under the PFS. Since we estimate that there are no significant 
impacts at the specialty level due to the proposed changes in RVUs 
resulting from the Fourth Five-Year Review of Work, the Secretary has 
determined that this proposed notice will not have a significant impact 
on the operations of a substantial number of small businesses or other 
small entities. Therefore, the Secretary has determined that this 
proposed notice will not have a significant economic impact on a 
substantial number of small entities.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule may have a significant impact on 
the operations of a substantial number of small rural hospitals. This 
analysis must conform to the provisions of section 603 of the RFA. For 
purposes of section 1102(b) of the Act, we define a small rural 
hospital as a hospital that is located outside of a metropolitan 
statistical area and has fewer than 100 beds. We do not believe that 
there will be significant impacts on small rural hospitals given the 
overall insignificant impact attributable to proposed RVU changes 
resulting from this Five-Year Review of Work. Therefore, the Secretary 
has determined that this proposed notice will not have a significant 
impact on the operations of a substantial number of small rural 
hospitals.
    Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) 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. In 2011, that 
threshold is approximately $136 million. This proposed notice will not 
mandate any requirements for State, local, or Tribal governments in the 
aggregate, or by the private sector, of $135 million. Medicare 
beneficiaries are considered to be part of the private sector and as a 
result a more detailed discussion is presented on the Impact of 
Beneficiaries in section V.C. of this proposed notice.
    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. We have examined this proposed notice in accordance with 
Executive Order 13132 and have determined that this regulation would 
not have any substantial direct effect on State or local governments, 
preempt States, or otherwise have a Federalism implication.

B. Anticipated Effects: Impact on Beneficiaries

    Overall, we believe these changes would improve beneficiary access 
to reasonable and necessary services since services would be more 
appropriately valued. The payment changes could also affect beneficiary 
liability. Any changes in aggregate beneficiary liability from a 
particular work RVU change would be negligible; however, an individual 
beneficiary's liability would be a function of the coinsurance (20 
percent, if applicable, for the particular service after the 
beneficiary has met the deductible) and the effect of the work RVU 
changes on the calculation of the Medicare Part B payment rate for the 
service.

C. Alternatives Considered

    This proposed notice discusses the proposed revisions to the work 
RVUs and corresponding changes to the PE and malpractice RVUs under the 
PFS. The preamble provides descriptions of the statutory provisions 
that are addressed, identifies those areas when discretion has been 
exercised, presents rationale for our decisions, and where relevant, 
alternatives that were considered.

D. Accounting Statement and Table

    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/sites/default/files/omb/assets/omb/circulars/a004/a-4.pdf), in Table 8, we have prepared an accounting statement showing 
the estimated expenditures associated with this proposed notice.

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E. Conclusion

    As stated previously, the Secretary determined that the economic 
impacts of this proposed notice do not meet the level required by 
section 1102(b) of the Act or the RFA and, therefore, we are not 
providing a regulatory impact analysis.
    In accordance with the provisions of Executive Order 12866, this 
proposed notice was reviewed by the Office of Management and Budget.

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: March 31, 2011.
Donald M. Berwick,
Administrator, Centers for Medicare & Medicaid Services.
    Approved: April 28, 2011.
Kathleen Sebelius,
Secretary, Department of Health and Human Services.

ADDENDUM A: EXPLANATION AND USE OF ADDENDA B AND C

    The Addenda on the following pages provide various data 
pertaining to the Medicare fee schedule for physicians' services 
furnished in CY 2012. Addendum B contains the RVUs for work, 
nonfacility PE, facility PE, and malpractice expense, and other 
information for all services included in the PFS. We note that for 
this proposed notice, to create Addendum B, we retained the current 
CY 2011 RVUs from the CY 2011 payment file for most codes and 
displayed new RVUs for only those codes involved in the Fourth Five-
Year Review of Work. PE RVUs for these Five-Year Review codes were 
calculated using CY 2009 Medicare utilization data in order to 
maintain consistency with the current CY 2011 RVUs displayed for all 
other services. Addendum C contains the list of CPT codes that were 
reviewed for the Fourth Five-Year Review of Work.
    (1) Addendum B: Relative Value Units and Related Information 
Used in Determining Payments for CY 2012 (Changes from CY 2011 for 
Services Reviewed in the Fourth Five-Year Review Only)
    In previous years, we have listed many services in Addendum B 
that are not paid under the PFS. To avoid publishing as many pages 
of codes for these services, we are not including clinical 
laboratory codes or the alpha-numeric codes (Healthcare Common 
Procedure Coding System (HCPCS) codes not included in CPT) not paid 
under the PFS in Addendum B.
    Addendum B contains the following information for each CPT code 
and alpha-numeric HCPCS code, except for: Alpha-numeric codes 
beginning with B (enteral and parenteral therapy); E (durable 
medical equipment); K (temporary codes for nonphysicians' services 
or items); or L (orthotics); and codes for anesthesiology. Please 
also note the following:
     An ``NA'' in the ``Nonfacility PE RVUs'' column of 
Addendum B means that CMS has not developed a PE RVU in the 
nonfacility setting for the service because it is typically 
performed in the hospital (for example, an open heart surgery is 
generally performed in the hospital setting and not a physician's 
office). If there is an ``NA'' in the nonfacility PE RVU column, and 
the contractor determines that this service can be performed in the 
nonfacility setting, the service will be paid at the facility PE RVU 
rate.
     Services that have an ``NA'' in the ``Facility PE 
RVUs'' column of Addendum B are typically not paid under the PFS 
when provided in a facility setting. These services (which include 
``incident to'' services and the technical portion of diagnostic 
tests) are generally paid under either the hospital outpatient 
prospective payment system or bundled into the hospital inpatient 
prospective payment system payment. In some cases, these services 
may be paid in a facility setting at the PFS rate (for example, 
therapy services), but there would be no payment made to the 
practitioner under the PFS in these situations.
    1. CPT/HCPCS code. This is the CPT or alpha-numeric HCPCS number 
for the service. Alpha-numeric HCPCS codes are included at the end 
of this Addendum.
    2. Modifier. A modifier is shown if there is a technical 
component (modifier TC) and a professional component (PC) (modifier-
26) for the service. If there is a PC and a TC for the service, 
Addendum B contains three entries for the code. A code for: the 
global values (both professional and technical); modifier-26 (PC); 
and modifier TC. The global service is not designated by a modifier, 
and physicians must bill using the code without a modifier if the 
physician furnishes both the PC and the TC of the service. Modifier-
53 is shown for a discontinued procedure, for example, a colonoscopy 
that is not completed. There will be RVUs for a code with this 
modifier.
    3. Status indicator. This indicator shows whether the CPT/HCPCS 
code is included in the PFS and whether it is separately payable if 
the service is covered. An explanation of types of status indicators 
follows:
    A = Active code. These codes are separately payable under the 
PFS if covered. There will be RVUs for codes with this status. The 
presence of an ``A'' indicator does not mean that Medicare has made 
a national coverage determination regarding the service. Contractors 
remain responsible for coverage decisions in the absence of a 
national Medicare policy.
    B = Bundled code. Payments for covered services are always 
bundled into payment for other services not specified. If RVUs are 
shown, they are not used for Medicare payment. If these services are 
covered, payment for them is subsumed by the payment for the 
services to which they are incident (for example, a telephone call 
from a hospital nurse regarding care of a patient).
    C = Contractors price the code. Contractors establish RVUs and 
payment amounts for these services, generally on an individual case 
basis following review of documentation, such as an operative 
report.
    E = Excluded from the PFS by regulation. These codes are for 
items and services that CMS chose to exclude from the PFS by 
regulation. No RVUs are shown, and no payment may be made under the 
PFS for these codes. Payment for them, when covered, continues under 
reasonable charge procedures.
    I = Not valid for Medicare purposes. Medicare uses another code 
for the reporting of, and the payment for these services. (Codes not 
subject to a 90 day grace period.)
    M = Measurement codes, used for reporting purposes only. There 
are no RVUs and no payment amounts for these codes. CMS uses them to 
aid with performance measurement. No separate payment is made. These 
codes should be billed with a zero (($0.00) charge and are denied) 
on the MPFSDB.
    N = Non-covered service. These codes are noncovered services. 
Medicare payment may not be made for these codes. If RVUs are shown, 
they are not used for Medicare payment.
    R = Restricted coverage. Special coverage instructions apply. If 
the service is covered and no RVUs are shown, it is contractor-
priced.
    T = There are RVUs for these services, but they are only paid if 
there are no other

[[Page 32472]]

services payable under the PFS billed on the same date by the same 
provider. If any other services payable under the PFS are billed on 
the same date by the same provider, these services are bundled into 
the service(s) for which payment is made.
    X = Statutory exclusion. These codes represent an item or 
service that is not within the statutory definition of ``physicians' 
services'' for PFS payment purposes. No RVUs are shown for these 
codes, and no payment may be made under the PFS, (for example, 
ambulance services and clinical diagnostic laboratory services.)
    4. Description of code. This is the code's short descriptor, 
which is an abbreviated version of the narrative description of the 
code.
    5. Physician work RVUs. These are the RVUs for the physician 
work in CY 2011.
    6. Fully implemented nonfacility PE RVUs. These are the fully 
implemented resource-based PE RVUs for nonfacility settings.
    7. CY 2011 transitional nonfacility PE RVUs. These are the CY 
2011 resource-based PE RVUs for nonfacility settings.
    8. Fully implemented facility PE RVUs. These are the fully 
implemented resource-based PE RVUs for facility settings.
    9. CY 2011 Transitional facility PE RVUs. These are the CY 2011 
resource-based PE RVUs for facility settings.
    10. Malpractice expense RVUs. These are the RVUs for the 
malpractice expense for CY 2011.
    11. Global period. This indicator shows the number of days in 
the global period for the code (0, 10, or 90 days). An explanation 
of the alpha codes follows:
    MMM = Code describes a service furnished in uncomplicated 
maternity cases, including ante partum care, delivery, and 
postpartum care. The usual global surgical concept does not apply. 
See the Physicians' Current Procedural Terminology for specific 
definitions.
    XXX = The global concept does not apply.
    YYY = The global period is to be set by the contractor (for 
example, unlisted surgery codes).
    ZZZ = Code related to another service that is always included in 
the global period of the other service.

(2) Addendum C: Codes With Proposed RVUs Subject to Comment for Fourth 
Five-Year Review of Work

    Addendum C includes the columns and indicators described above 
for Addendum B for codes with proposed RVUs subject to comment for 
the Fourth Five-Year Review of Work.
BILLING CODE P

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[FR Doc. 2011-13052 Filed 5-24-11; 4:15 pm]
BILLING CODE C